Illinois 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 Illinois Sample Letter for Request for Medical Records [Your Name] [Your Address] [City, State, ZIP] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP] Dear [Healthcare Provider's Name], RE: REQUEST FOR MEDICAL RECORDS I am writing to formally request copies of my medical records in accordance with the Illinois Medical Patient Rights Act (ILPGA) and the Health Insurance Portability and Accountability Act (HIPAA). I have been a patient at your facility, [Facility Name], from [Dates of Treatment]. I have recently changed healthcare providers and would like to obtain my complete medical records for continuity of care purposes. To expedite the process, I have enclosed a signed and completed Authorization for Release of Medical Records form, which meets HIPAA regulations (or include any specific form required by the healthcare provider). Please find the necessary information filled in accurately to assist you in locating my records promptly. In compliance with Illinois state law, I understand that I may be charged a reasonable fee for the duplication of medical records. However, I kindly request that you inform me about the associated charges before proceeding with the request. Please provide the following medical records: 1. Consultation notes 2. Hospital admission and discharge summaries 3. Laboratory reports and test results 4. Radiology and imaging reports (x-rays, MRI, CT scans, etc.) 5. Progress notes 6. Pathology reports, if applicable 7. Medication and prescription history 8. Allergies and adverse reaction records 9. Diagnostic reports 10. Immunization history, if available Is there are any additional records or details relevant to my medical history which are not listed above, please include them as well. I would greatly appreciate it if you could provide these records in an electronic format, preferably via secure email or a password-protected online portal. If electronic transmission is not feasible, please inform me of the available options. Please acknowledge receipt of this request within five business days and provide an estimate of when the records will be ready for collection. I understand that HIPAA allows a maximum of 30 days to fulfill this request, but I sincerely hope it can be done sooner to ensure uninterrupted healthcare management. Thank you for your attention to this matter. Should you have any questions or require further clarification, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address]. I look forward to a prompt response. Yours sincerely, [Your Name]

Illinois Sample Letter for Request for Medical Records [Your Name] [Your Address] [City, State, ZIP] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP] Dear [Healthcare Provider's Name], RE: REQUEST FOR MEDICAL RECORDS I am writing to formally request copies of my medical records in accordance with the Illinois Medical Patient Rights Act (ILPGA) and the Health Insurance Portability and Accountability Act (HIPAA). I have been a patient at your facility, [Facility Name], from [Dates of Treatment]. I have recently changed healthcare providers and would like to obtain my complete medical records for continuity of care purposes. To expedite the process, I have enclosed a signed and completed Authorization for Release of Medical Records form, which meets HIPAA regulations (or include any specific form required by the healthcare provider). Please find the necessary information filled in accurately to assist you in locating my records promptly. In compliance with Illinois state law, I understand that I may be charged a reasonable fee for the duplication of medical records. However, I kindly request that you inform me about the associated charges before proceeding with the request. Please provide the following medical records: 1. Consultation notes 2. Hospital admission and discharge summaries 3. Laboratory reports and test results 4. Radiology and imaging reports (x-rays, MRI, CT scans, etc.) 5. Progress notes 6. Pathology reports, if applicable 7. Medication and prescription history 8. Allergies and adverse reaction records 9. Diagnostic reports 10. Immunization history, if available Is there are any additional records or details relevant to my medical history which are not listed above, please include them as well. I would greatly appreciate it if you could provide these records in an electronic format, preferably via secure email or a password-protected online portal. If electronic transmission is not feasible, please inform me of the available options. Please acknowledge receipt of this request within five business days and provide an estimate of when the records will be ready for collection. I understand that HIPAA allows a maximum of 30 days to fulfill this request, but I sincerely hope it can be done sooner to ensure uninterrupted healthcare management. Thank you for your attention to this matter. Should you have any questions or require further clarification, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address]. I look forward to a prompt response. Yours sincerely, [Your Name]