Massachusetts Sample Letter for Request for Medical Records [Your Name] [Your Address] [City, State, ZIP] [Date] [Name of Health Care Facility] [Address] [City, State, ZIP] Subject: Request for Release of Medical Records Dear [Name of Health Care Facility], I hope this letter finds you well. I am writing to request a copy of my complete medical records as maintained by your facility, in accordance with my rights under state and federal health information privacy laws, specifically the Health Insurance Portability and Accountability Act (HIPAA). I have been a patient at your facility for [duration of treatment or relevant period], and I believe it is essential to have access to my medical records for personal reference, future medical care, and continuity of care. Therefore, I kindly request that you provide me with a complete copy of my medical records dating back to the beginning of my treatment with your facility. To assist you in processing my request promptly, I have included the following information: 1. Full Name: [Your Full Name] 2. Date of Birth: [Your Date of Birth] 3. Patient ID/Account Number: [If applicable] 4. Dates of Treatment: [Provide a range or specific dates if known] 5. Specific Records Requested: [Specify any relevant medical documents or diagnoses you are particularly interested in obtaining] To ensure proper identification of my records, please find enclosed a photocopy of my driver's license/passport or any other government-issued identification document. If there are any additional forms or fees required to process my request, please inform me at your earliest convenience. As stated by Massachusetts law, Chapter 111, section 70, you are required to provide me with a copy of my medical records within 30 days of receiving this request. In case any costly reproduction fees apply, please notify me beforehand. I am willing to cover reasonable expenses associated with this request. If you have any questions or require further information, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address]. I greatly appreciate your attention to this matter and your cooperation in providing me with the requested medical records. Thank you for your prompt attention to this matter and for your cooperation. Sincerely, [Your Name] [Your Signature] Massachusetts Sample Letters for Request for Medical Records may include variations based on the specific circumstances involved, such as: 1. Letter for Requesting Spouse's Medical Records: If you are legally authorized to access your spouse's medical records, you may modify the letter to specify the relationship and attach relevant legal documents supporting your authorization. 2. Letter for Requesting Minor's Medical Records: In the case of a minor, a parent or legal guardian should provide a letter requesting the child's medical records, along with appropriate legal documentation to establish guardianship or parental rights. 3. Letter for Requesting Records on Behalf of Deceased Patients: When requesting medical records for a deceased individual, the letter should be adjusted to reflect your relationship to the deceased and include appropriate supporting documents, such as a death certificate, executor ship papers, or next of kin authorization. 4. Letter for Requesting Psychiatric or Psychotherapy Records: If you are specifically seeking psychiatric or psychotherapy records, you may choose to modify the letter to mention your interest in obtaining these specific records, which may require additional steps or consent as per Massachusetts laws. Remember, it is essential to adapt the sample letter to your specific situation and adhere to any additional requirements outlined by your healthcare provider or Massachusetts state laws.
Massachusetts Sample Letter for Request for Medical Records
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