Guam 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] [Medical Provider's Name] [Medical Provider's Address] [City, State, Zip Code] Subject: Request for Patient Medical Records Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to request the release of my medical records as a patient at your facility, [Facility Name]. I require these records for personal reference as well as for potential second opinions and continuation of my medical care. As per the guidelines provided by the Guam Department of Public Health and Social Services, it is my right to have access to my medical records. I kindly request that you provide me with copies of the following documents from the date of my first visit to your facility: 1. Medical history, including all diagnoses, treatments, and surgeries 2. Laboratory test results, including blood work, imaging reports, and pathology reports 3. Medication and prescription history, including dosage information 4. All progress notes and treatment plans 5. All correspondence with other healthcare providers pertaining to my care 6. Records of any consultations or referrals made to other specialists 7. Records of any allergies, adverse reactions, or side effects experienced 8. Any other relevant medical information pertaining to my treatments and conditions I understand that there may be a fee associated with the copying and preparation of these records. Therefore, please inform me of any charges beforehand so that I can make the necessary arrangements for payment. To ensure the timely processing of my request, I have included the following necessary identification documents: 1. A copy of my valid photo identification (e.g., passport, driver's license) 2. A signed and dated authorization form attached to this letter I kindly request that you provide the copies of my medical records within [mention a reasonable timeframe, e.g., 30 days] from the date of this letter. If it is not possible to fulfill my request within this timeframe, I would appreciate being notified in writing with an estimated completion date. Please note that the Health Insurance Portability and Accountability Act (HIPAA) requires healthcare providers to fulfill patient requests for medical records within 30 days, excluding any permissible extensions. I trust that you will uphold your obligations under this law. Should you have any questions or require further clarification, please do not hesitate to contact me at [Your Phone Number] or via email at [Your Email Address]. I appreciate your prompt attention to this matter. Thank you for your cooperation. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, Zip Code] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, Zip Code] Subject: Request for Patient Medical Records Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to request the release of my medical records as a patient at your facility, [Facility Name]. I require these records for personal reference as well as for potential second opinions and continuation of my medical care. As per the guidelines provided by the Guam Department of Public Health and Social Services, it is my right to have access to my medical records. I kindly request that you provide me with copies of the following documents from the date of my first visit to your facility: 1. Medical history, including all diagnoses, treatments, and surgeries 2. Laboratory test results, including blood work, imaging reports, and pathology reports 3. Medication and prescription history, including dosage information 4. All progress notes and treatment plans 5. All correspondence with other healthcare providers pertaining to my care 6. Records of any consultations or referrals made to other specialists 7. Records of any allergies, adverse reactions, or side effects experienced 8. Any other relevant medical information pertaining to my treatments and conditions I understand that there may be a fee associated with the copying and preparation of these records. Therefore, please inform me of any charges beforehand so that I can make the necessary arrangements for payment. To ensure the timely processing of my request, I have included the following necessary identification documents: 1. A copy of my valid photo identification (e.g., passport, driver's license) 2. A signed and dated authorization form attached to this letter I kindly request that you provide the copies of my medical records within [mention a reasonable timeframe, e.g., 30 days] from the date of this letter. If it is not possible to fulfill my request within this timeframe, I would appreciate being notified in writing with an estimated completion date. Please note that the Health Insurance Portability and Accountability Act (HIPAA) requires healthcare providers to fulfill patient requests for medical records within 30 days, excluding any permissible extensions. I trust that you will uphold your obligations under this law. Should you have any questions or require further clarification, please do not hesitate to contact me at [Your Phone Number] or via email at [Your Email Address]. I appreciate your prompt attention to this matter. Thank you for your cooperation. Sincerely, [Your Name]