Alaska Sample Letter for Request for Patient Medical Records

• Category: Letters - Nonlegal - Medical
• State: Multi-State
• Control #: US-0328LR
• Format: Word; Rich Text

Description

This form is a sample letter in Word format covering the subject matter of the title of the form. [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Recipient's Name] [Recipient's Title] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP Code] Subject: Request for Patient Medical Records Dear [Recipient's Name], I hope this letter finds you in good health and high spirits. I am writing to request a copy of my medical records from [Healthcare Provider's Name]. As an Alaska resident, I believe it is my right to access and maintain a complete record of my health history. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Address: [Patient's Address— - Contact Number: [Patient's Phone Number] I kindly request you to provide me with a complete copy of my medical records. I understand that this includes all pertinent information, such as: 1. Medical history and diagnoses 2. Laboratory and diagnostic test results 3. Medication and prescription details 4. Treatment plans and progress notes 5. Immunization records 6. Surgical and operative reports 7. Allergies and adverse reactions 8. Vital signs and measurements 9. Consultation and referral records 10. Any other relevant medical information As per the Alaska Revised Code — Title 08, Chapter 42, Section 345, I am aware that I may be charged a reasonable fee for photocopying and processing my medical records. I am willing to cover these expenses and request that you inform me of the estimated cost in advance. To ensure a prompt and efficient retrieval process, I kindly ask you to provide the medical records within 30 days of receiving this request, as mandated by the HIPAA Privacy Rule. Furthermore, I would appreciate it if the records are provided in an electronic format, such as a secure PDF or CD. Please let me know if there are any additional forms or documents required to complete this process. You may reach me at the provided contact information to discuss any concerns or queries related to this request. I trust that you understand the importance of this matter and will promptly address my request. Thank you for your attention to this matter. I look forward to receiving my medical records in due course. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Recipient's Name] [Recipient's Title] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP Code] Subject: Request for Patient Medical Records Dear [Recipient's Name], I hope this letter finds you in good health and high spirits. I am writing to request a copy of my medical records from [Healthcare Provider's Name]. As an Alaska resident, I believe it is my right to access and maintain a complete record of my health history. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Address: [Patient's Address— - Contact Number: [Patient's Phone Number] I kindly request you to provide me with a complete copy of my medical records. I understand that this includes all pertinent information, such as: 1. Medical history and diagnoses 2. Laboratory and diagnostic test results 3. Medication and prescription details 4. Treatment plans and progress notes 5. Immunization records 6. Surgical and operative reports 7. Allergies and adverse reactions 8. Vital signs and measurements 9. Consultation and referral records 10. Any other relevant medical information As per the Alaska Revised Code — Title 08, Chapter 42, Section 345, I am aware that I may be charged a reasonable fee for photocopying and processing my medical records. I am willing to cover these expenses and request that you inform me of the estimated cost in advance. To ensure a prompt and efficient retrieval process, I kindly ask you to provide the medical records within 30 days of receiving this request, as mandated by the HIPAA Privacy Rule. Furthermore, I would appreciate it if the records are provided in an electronic format, such as a secure PDF or CD. Please let me know if there are any additional forms or documents required to complete this process. You may reach me at the provided contact information to discuss any concerns or queries related to this request. I trust that you understand the importance of this matter and will promptly address my request. Thank you for your attention to this matter. I look forward to receiving my medical records in due course. Sincerely, [Your Name]