Guam Sample Letter for Request for Medical Records

• Category: Letters - Nonlegal - Requests
• State: Multi-State
• Control #: US-0546LR
• Format: Word; Rich Text

Description

Sample Letter for Request for Medical Records [Your Name] [Your Address] [City, State, Zip Code] [Email Address] [Phone Number] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, Zip Code] Subject: Request for Medical Records Dear [Healthcare Provider's Name], I hope this letter finds you in good health. I am writing to request copies of my medical records for the purpose of [state the reason why you need them, e.g., personal medical records management, obtaining a second opinion, transfer of care, legal purposes, insurance claims, etc.]. To facilitate this request, I have provided essential information related to my medical history below: 1. Full Name: [Your Full Name] 2. Date of Birth: [Your Date of Birth] 3. Social Security Number (optional): [Your SSN] 4. Patient ID (if applicable): [Your Patient ID] 5. Dates of Service: [Specify the range of dates or a specific timeframe for the records you require] I kindly ask that you provide copies of the following documents: 1. Consultation notes 2. Laboratory test results 3. Radiology reports (X-rays, MRIs, CT scans, etc.) 4. Immunization records 5. Medication list and prescriptions 6. Surgical reports 7. Pathology reports 8. Progress notes 9. All correspondence related to my care 10. Any other relevant medical documentation As per the Health Insurance Portability and Accountability Act (HIPAA) and other applicable laws, I understand that I may be charged reasonable fees for copying and releasing my medical records. Please inform me about the associated costs, if applicable, before proceeding with the request. If it is more convenient and secure for you, I am open to receiving the medical records electronically via email or a secure online portal. Please let me know if this is a possibility and provide any necessary instructions. I would appreciate it if you could process my request in a timely manner. If there is any additional documentation or verification required, please don't hesitate to contact me. I can be reached at the phone number or email address provided above. Thank you very much for your prompt attention to this matter. I value your commitment to patient care and believe that obtaining my complete medical records from your esteemed institution is essential for ensuring continuity in my healthcare. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, Zip Code] [Email Address] [Phone Number] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, Zip Code] Subject: Request for Medical Records Dear [Healthcare Provider's Name], I hope this letter finds you in good health. I am writing to request copies of my medical records for the purpose of [state the reason why you need them, e.g., personal medical records management, obtaining a second opinion, transfer of care, legal purposes, insurance claims, etc.]. To facilitate this request, I have provided essential information related to my medical history below: 1. Full Name: [Your Full Name] 2. Date of Birth: [Your Date of Birth] 3. Social Security Number (optional): [Your SSN] 4. Patient ID (if applicable): [Your Patient ID] 5. Dates of Service: [Specify the range of dates or a specific timeframe for the records you require] I kindly ask that you provide copies of the following documents: 1. Consultation notes 2. Laboratory test results 3. Radiology reports (X-rays, MRIs, CT scans, etc.) 4. Immunization records 5. Medication list and prescriptions 6. Surgical reports 7. Pathology reports 8. Progress notes 9. All correspondence related to my care 10. Any other relevant medical documentation As per the Health Insurance Portability and Accountability Act (HIPAA) and other applicable laws, I understand that I may be charged reasonable fees for copying and releasing my medical records. Please inform me about the associated costs, if applicable, before proceeding with the request. If it is more convenient and secure for you, I am open to receiving the medical records electronically via email or a secure online portal. Please let me know if this is a possibility and provide any necessary instructions. I would appreciate it if you could process my request in a timely manner. If there is any additional documentation or verification required, please don't hesitate to contact me. I can be reached at the phone number or email address provided above. Thank you very much for your prompt attention to this matter. I value your commitment to patient care and believe that obtaining my complete medical records from your esteemed institution is essential for ensuring continuity in my healthcare. Sincerely, [Your Name]