Ejemplo De Carta Médica - Sample Letter for Request for Medical Records

• Category: Cartas - No legales - Solicitudes
• State: Multi-State
• County: Suffolk
• Control #: US-0546LR
• Format: Word

Description

Carta de solicitud de registros médicos. [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Healthcare Facility Name] [Healthcare Facility Address] [City, State, ZIP Code] Subject: Request for Medical Records Dear [Healthcare Facility Name], I am writing to request copies of my medical records for the purpose of [state the reason why you need the records, e.g., continued care, personal records, legal matters, or substantiating insurance claims]. I have previously received medical treatment at your facility and would greatly appreciate your assistance in providing me with the following information: 1. Personal Information: — Full legal name: [Your Full Legal Name] — Date of birth: [Your Date of Birth— - Social Security Number: [Your SSN, optional] 2. Dates of Medical Treatment/Visits: I kindly request copies of my medical records for the period between [Start Date] and [End Date]. Please include all visits, treatments, diagnostic tests, surgical procedures, medications prescribed or administered, laboratory test results, and any corresponding narratives from healthcare providers. 3. Records Format: Please provide the requested medical records in electronic format, if available. If not feasible, kindly make arrangements for physical copies to be sent to my address mentioned above. 4. Authorization and Signature: I understand that releasing my medical records requires my authorization. Enclosed you will find a signed HIPAA Release Form, authorizing the release of my medical records to me. Please find it attached to this letter. 5. Payment: If there is any cost associated with obtaining the requested medical records, please inform me in advance. I am ready to reimburse any reasonable fees required for the processing and copying of my medical records, as permitted by law. I kindly request completing this request within the legal time frame as designated by state and federal regulations. Should you require any additional information or have any questions, please do not hesitate to contact me at the phone number or email address provided above. Thank you in advance for your prompt attention to this matter. Your assistance will greatly facilitate the continuation of my healthcare and support any necessary administrative processes. Sincerely, [Your Full Name] Attachments: — HIPAA Release Form

[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Healthcare Facility Name] [Healthcare Facility Address] [City, State, ZIP Code] Subject: Request for Medical Records Dear [Healthcare Facility Name], I am writing to request copies of my medical records for the purpose of [state the reason why you need the records, e.g., continued care, personal records, legal matters, or substantiating insurance claims]. I have previously received medical treatment at your facility and would greatly appreciate your assistance in providing me with the following information: 1. Personal Information: — Full legal name: [Your Full Legal Name] — Date of birth: [Your Date of Birth— - Social Security Number: [Your SSN, optional] 2. Dates of Medical Treatment/Visits: I kindly request copies of my medical records for the period between [Start Date] and [End Date]. Please include all visits, treatments, diagnostic tests, surgical procedures, medications prescribed or administered, laboratory test results, and any corresponding narratives from healthcare providers. 3. Records Format: Please provide the requested medical records in electronic format, if available. If not feasible, kindly make arrangements for physical copies to be sent to my address mentioned above. 4. Authorization and Signature: I understand that releasing my medical records requires my authorization. Enclosed you will find a signed HIPAA Release Form, authorizing the release of my medical records to me. Please find it attached to this letter. 5. Payment: If there is any cost associated with obtaining the requested medical records, please inform me in advance. I am ready to reimburse any reasonable fees required for the processing and copying of my medical records, as permitted by law. I kindly request completing this request within the legal time frame as designated by state and federal regulations. Should you require any additional information or have any questions, please do not hesitate to contact me at the phone number or email address provided above. Thank you in advance for your prompt attention to this matter. Your assistance will greatly facilitate the continuation of my healthcare and support any necessary administrative processes. Sincerely, [Your Full Name] Attachments: — HIPAA Release Form

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.