Indiana 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. Indiana Sample Letter for Request for Patient Medical Records Dear [Healthcare Provider/Health Information Management Department], I am writing to formally request access to my/our medical records as permitted by the laws and regulations governing patient information privacy, specifically the Health Insurance Portability and Accountability Act (HIPAA) and the Indiana Medical Records Act. Patient Information: Full Name: [Patient's Full Name] Date of Birth: [Patient's Date of Birth] Address: [Patient's Address] Contact Number: [Patient's Contact Number] Email Address: [Patient's Email Address] Medical Record Number: [Patient's Medical Record Number] I hereby authorize the release of my/our complete medical records, including but not limited to: 1. Office visit summaries and progress notes 2. Laboratory test results 3. Radiology reports and images 4. Surgical and procedure reports 5. Consultation and referral notes 6. Medication lists and prescription history 7. Immunization records 8. Allergies and adverse reactions 9. Pathology and biopsy reports 10. Mental health records (if applicable) 11. Any other relevant medical information pertaining to my/our healthcare Please provide these records in either electronic format (e.g., CD-ROM, USB drive) or as hard copies, whichever is most convenient for your facility. I understand that there may be a reasonable fee associated with reproducing these records, and I am prepared to cover any costs incurred in this process. I request expedited processing of this request due to urgent medical needs or for continuing care purposes. If it is not feasible to fulfill this request within the required timeframe, please let me know as soon as possible. Please provide me with a written acknowledgement of this request within the next 10 business days, as per Indiana law. It is essential that I receive a response regarding the estimated timeline for the release of my medical records. If there are any necessary forms or additional steps I need to complete, kindly inform me promptly. If there are any concerns or questions regarding this request, please do not hesitate to contact me using the provided contact information. I would appreciate your cooperation in ensuring the prompt release of my medical records. Thank you for your attention to this matter, and I look forward to a timely response. Sincerely, [Patient's Full Name] [Patient's Signature] Enclosures: — Copy of valid photo identification (e.g., driver's license, passport) — Any relevant supporting documentation (e.g., power of attorney, legal guardian documentation)

Indiana Sample Letter for Request for Patient Medical Records Dear [Healthcare Provider/Health Information Management Department], I am writing to formally request access to my/our medical records as permitted by the laws and regulations governing patient information privacy, specifically the Health Insurance Portability and Accountability Act (HIPAA) and the Indiana Medical Records Act. Patient Information: Full Name: [Patient's Full Name] Date of Birth: [Patient's Date of Birth] Address: [Patient's Address] Contact Number: [Patient's Contact Number] Email Address: [Patient's Email Address] Medical Record Number: [Patient's Medical Record Number] I hereby authorize the release of my/our complete medical records, including but not limited to: 1. Office visit summaries and progress notes 2. Laboratory test results 3. Radiology reports and images 4. Surgical and procedure reports 5. Consultation and referral notes 6. Medication lists and prescription history 7. Immunization records 8. Allergies and adverse reactions 9. Pathology and biopsy reports 10. Mental health records (if applicable) 11. Any other relevant medical information pertaining to my/our healthcare Please provide these records in either electronic format (e.g., CD-ROM, USB drive) or as hard copies, whichever is most convenient for your facility. I understand that there may be a reasonable fee associated with reproducing these records, and I am prepared to cover any costs incurred in this process. I request expedited processing of this request due to urgent medical needs or for continuing care purposes. If it is not feasible to fulfill this request within the required timeframe, please let me know as soon as possible. Please provide me with a written acknowledgement of this request within the next 10 business days, as per Indiana law. It is essential that I receive a response regarding the estimated timeline for the release of my medical records. If there are any necessary forms or additional steps I need to complete, kindly inform me promptly. If there are any concerns or questions regarding this request, please do not hesitate to contact me using the provided contact information. I would appreciate your cooperation in ensuring the prompt release of my medical records. Thank you for your attention to this matter, and I look forward to a timely response. Sincerely, [Patient's Full Name] [Patient's Signature] Enclosures: — Copy of valid photo identification (e.g., driver's license, passport) — Any relevant supporting documentation (e.g., power of attorney, legal guardian documentation)