Arkansas 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. Subject: Request for Patient Medical Records — Arkansas Sample Letter Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to request copies of my medical records from [Healthcare Facility/Hospital/Clinic] located in the state of Arkansas. As a patient, I have the right to access my personal health information under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. I recently received medical care at your esteemed facility from [Date] to [Date], and I would greatly appreciate it if you could provide me with a complete copy of my medical records pertaining to that particular time period. In order to facilitate the process, I have outlined the details regarding my request below: 1. Full Patient Name: [Your Full Name] 2. Date of Birth: [Your Date of Birth] 3. Medical Record Number (if available): 4. Date(s) of Service: [Specific dates or date range of the treatment received] 5. Type of Treatment: [Briefly describe the reason for your visit, e.g., Diagnostic tests, surgical intervention, consultation, etc.] Please note that I am including a signed authorization form, as required by HIPAA regulations, to ensure compliance and to grant permission for the release of my medical records to me. Additionally, I understand that there may be a reasonable fee associated with this request for copying and mailing the records, as allowed under the state and federal regulations.× I would appreciate if you can provide me with the estimated cost and inform me of the payment procedure. I kindly request that the medical records are provided to me within the reasonable timeframe allowed under the applicable state and federal regulations. Should there be any delay or difficulty in fulfilling this request, please inform me promptly with an estimated timeframe or any necessary clarification required. Please forward the requested medical records to the address mentioned below: [Your Full Name] [Your Mailing Address] [City, State, ZIP Code] I thank you in advance for your prompt attention to this matter and for your assistance in fulfilling my request. If you have any queries or require any additional information, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address]. Sincerely, [Your Full Name] *Types of Arkansas Sample Letters for Request for Patient Medical Records: — Arkansas Sample Letter for Request for Patient Medical Records — StandarRequestes— - Arkansas Sample Letter for Request for Patient Medical Records — UrgenRequestes— - Arkansas Sample Letter for Request for Minor Patient Medical Records — Arkansas Sample Letter for Request for Deceased Patient Medical Records

Subject: Request for Patient Medical Records — Arkansas Sample Letter Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to request copies of my medical records from [Healthcare Facility/Hospital/Clinic] located in the state of Arkansas. As a patient, I have the right to access my personal health information under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. I recently received medical care at your esteemed facility from [Date] to [Date], and I would greatly appreciate it if you could provide me with a complete copy of my medical records pertaining to that particular time period. In order to facilitate the process, I have outlined the details regarding my request below: 1. Full Patient Name: [Your Full Name] 2. Date of Birth: [Your Date of Birth] 3. Medical Record Number (if available): 4. Date(s) of Service: [Specific dates or date range of the treatment received] 5. Type of Treatment: [Briefly describe the reason for your visit, e.g., Diagnostic tests, surgical intervention, consultation, etc.] Please note that I am including a signed authorization form, as required by HIPAA regulations, to ensure compliance and to grant permission for the release of my medical records to me. Additionally, I understand that there may be a reasonable fee associated with this request for copying and mailing the records, as allowed under the state and federal regulations.× I would appreciate if you can provide me with the estimated cost and inform me of the payment procedure. I kindly request that the medical records are provided to me within the reasonable timeframe allowed under the applicable state and federal regulations. Should there be any delay or difficulty in fulfilling this request, please inform me promptly with an estimated timeframe or any necessary clarification required. Please forward the requested medical records to the address mentioned below: [Your Full Name] [Your Mailing Address] [City, State, ZIP Code] I thank you in advance for your prompt attention to this matter and for your assistance in fulfilling my request. If you have any queries or require any additional information, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address]. Sincerely, [Your Full Name] *Types of Arkansas Sample Letters for Request for Patient Medical Records: — Arkansas Sample Letter for Request for Patient Medical Records — StandarRequestes— - Arkansas Sample Letter for Request for Patient Medical Records — UrgenRequestes— - Arkansas Sample Letter for Request for Minor Patient Medical Records — Arkansas Sample Letter for Request for Deceased Patient Medical Records