San Antonio Texas Ejemplo de carta de solicitud de registros médicos - Sample Letter for Request for Medical Records

• Category: Cartas - No legales - Solicitudes
• State: Multi-State
• City: San Antonio
• Control #: US-0546LR
• Format: Word

Description

Carta de solicitud de registros médicos. [Your Name] [Your Address] [City, State, Zip] [Date] [Recipient's Name] [Recipient's Address] [City, State, Zip] Subject: Request for Medical Records Dear [Recipient's Name], I hope this letter finds you well. I am writing to request copies of my medical records as I require them for [state the purpose of your request, e.g., continuation of treatment, a second opinion, personal records, etc.]. I have received healthcare services at a facility in San Antonio, Texas, and would appreciate your assistance in providing me with the necessary documentation. To facilitate this request, please find below the details necessary for the retrieval of my medical records: 1. Full name: [Your Full Name] 2. Date of Birth: [Your Date of Birth] 3. Social Security Number (optional but helpful for accurate record retrieval): [Your SSN] 4. Dates of medical services: [Specify the time range or specific dates of medical visits or treatments] 5. Name of the healthcare facility/doctor: [Name of the medical facility or physician you visited] In compliance with federal regulations, I understand that there may be fees associated with the reproduction and delivery of the requested records. Consequently, I am willing to pay reasonable charges as determined by the facility for this service. Please inform me of the estimated cost and the preferred method of payment. Additionally, I kindly request that the medical records be forwarded to me at the address mentioned above. If for any reason this is not possible, please inform me in writing and provide alternate instructions for record retrieval. I understand that the process of compiling and providing medical records may take some time, so I would appreciate your prompt attention to this matter. If there are any specific forms or further documentation required to fulfill this request, please let me know, and I will provide them promptly. Thank you for your attention to this matter. I look forward to your prompt response and the timely provision of my medical records. If you have any further questions or require any additional information, please do not hesitate to contact me at [Your Phone Number]. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, Zip] [Date] [Recipient's Name] [Recipient's Address] [City, State, Zip] Subject: Request for Medical Records Dear [Recipient's Name], I hope this letter finds you well. I am writing to request copies of my medical records as I require them for [state the purpose of your request, e.g., continuation of treatment, a second opinion, personal records, etc.]. I have received healthcare services at a facility in San Antonio, Texas, and would appreciate your assistance in providing me with the necessary documentation. To facilitate this request, please find below the details necessary for the retrieval of my medical records: 1. Full name: [Your Full Name] 2. Date of Birth: [Your Date of Birth] 3. Social Security Number (optional but helpful for accurate record retrieval): [Your SSN] 4. Dates of medical services: [Specify the time range or specific dates of medical visits or treatments] 5. Name of the healthcare facility/doctor: [Name of the medical facility or physician you visited] In compliance with federal regulations, I understand that there may be fees associated with the reproduction and delivery of the requested records. Consequently, I am willing to pay reasonable charges as determined by the facility for this service. Please inform me of the estimated cost and the preferred method of payment. Additionally, I kindly request that the medical records be forwarded to me at the address mentioned above. If for any reason this is not possible, please inform me in writing and provide alternate instructions for record retrieval. I understand that the process of compiling and providing medical records may take some time, so I would appreciate your prompt attention to this matter. If there are any specific forms or further documentation required to fulfill this request, please let me know, and I will provide them promptly. Thank you for your attention to this matter. I look forward to your prompt response and the timely provision of my medical records. If you have any further questions or require any additional information, please do not hesitate to contact me at [Your Phone Number]. Sincerely, [Your Name]

Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés. For your convenience, the complete English version of this form is attached below the Spanish version.