Alabama 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] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to formally request copies of my medical records from your facility in accordance with the Alabama Code § 22-21-8. As a patient, I have the legal right to access and obtain my medical records under the Health Insurance Portability and Accountability Act (HIPAA). Please find below my detailed information: Patient Name: [Patient's Full Name] Date of Birth: [Patient's Date of Birth] Address: [Patient's Address] Social Security Number: [Patient's SSN] Date(s) of Service: [Specify the range of dates or specific dates] Type of Records Requested: [Specify the type of records you are requesting, such as laboratory reports, imaging studies, consultation notes, operative reports, discharge summaries, etc.] I understand that there may be a fee associated with the retrieval and duplication of these records. Please inform me of any charges in advance, and if applicable, any additional charges related to mailing or delivery. I am prepared to provide payment for these fees upon your request. Additionally, I request that the copies of my medical records be provided to me in a commonly used electronic format (e.g., PDF, CD/DVD) to facilitate efficient and secure transfer. To ensure the process proceeds smoothly, kindly provide a response confirming receipt of this letter within 10 business days. If any further documentation or forms are necessary to complete this request, kindly include them in your response. Please forward the requested medical records to: [Your Preferred Address for Delivery] [City, State, ZIP] I appreciate your prompt attention to this matter. The requested records are vital for ongoing medical care and maintaining accurate personal health information. If you have any questions or require additional details, please do not hesitate to contact me. Thank you for your cooperation. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to formally request copies of my medical records from your facility in accordance with the Alabama Code § 22-21-8. As a patient, I have the legal right to access and obtain my medical records under the Health Insurance Portability and Accountability Act (HIPAA). Please find below my detailed information: Patient Name: [Patient's Full Name] Date of Birth: [Patient's Date of Birth] Address: [Patient's Address] Social Security Number: [Patient's SSN] Date(s) of Service: [Specify the range of dates or specific dates] Type of Records Requested: [Specify the type of records you are requesting, such as laboratory reports, imaging studies, consultation notes, operative reports, discharge summaries, etc.] I understand that there may be a fee associated with the retrieval and duplication of these records. Please inform me of any charges in advance, and if applicable, any additional charges related to mailing or delivery. I am prepared to provide payment for these fees upon your request. Additionally, I request that the copies of my medical records be provided to me in a commonly used electronic format (e.g., PDF, CD/DVD) to facilitate efficient and secure transfer. To ensure the process proceeds smoothly, kindly provide a response confirming receipt of this letter within 10 business days. If any further documentation or forms are necessary to complete this request, kindly include them in your response. Please forward the requested medical records to: [Your Preferred Address for Delivery] [City, State, ZIP] I appreciate your prompt attention to this matter. The requested records are vital for ongoing medical care and maintaining accurate personal health information. If you have any questions or require additional details, please do not hesitate to contact me. Thank you for your cooperation. Sincerely, [Your Name]