Maine 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. Subject: Request for Patient Medical Records from Maine Medical Facility Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to formally request copies of the medical records for [Patient's Full Name], who was under your care at your esteemed medical facility in Maine. I am aware of the importance of these records in maintaining a comprehensive medical history, and I would greatly appreciate your assistance in obtaining them. Patient Details: Full Name: [Patient's Full Name] Date of Birth: [Patient's Date of Birth] Address: [Patient's Address] Phone Number: [Patient's Phone Number] Below, I have provided the relevant details for the requested medical records: 1. Date Range: Please include all medical records available from [Start Date] to [End Date]. If possible, I kindly request that you provide records dating back to [Patient's Initial Visit Date] in order to establish a comprehensive medical history. 2. Specific Records: Kindly include all records related to diagnoses, assessments, medical history, treatments, medications prescribed, laboratory test results, X-rays, scans, surgical reports, referrals, and any other relevant details that have been documented during [Patient's Full Name]'s time under your care. 3. Method of Delivery: Please specify if the records can be delivered in electronic format or if I should collect them from your office in person. If electronic delivery is possible, kindly provide them in a secure and encrypted format to ensure patient privacy is maintained. 4. Authorization: I authorize the release of these medical records in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and any other applicable laws or regulations. If any fees associated with this request are required, please inform me in advance. 5. Timeframe: While I understand the process may take some time, I kindly request that you fulfill this request within 30 days from the date of this letter. Should there be any delays or difficulties in processing this request, please notify me promptly. Please find enclosed a signed Medical Records Release Form, as required by your facility. Should any additional documentation be necessary, kindly inform me as soon as possible, and I will gladly provide it. If you have any questions or require additional information, please do not hesitate to contact me at [Your Contact Number] or via email at [Your Email Address]. Thank you for considering this request, and I greatly appreciate your attention to detail and prompt assistance in this matter. Your cooperation is vital in ensuring the continuity of [Patient's Full Name]'s healthcare. I look forward to receiving the requested medical records soon. Sincerely, [Your Full Name] [Your Address] [City, State, ZIP] [Your Contact Number] [Your Email Address] Enclosure: — Medical Records Release Form

Subject: Request for Patient Medical Records from Maine Medical Facility Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to formally request copies of the medical records for [Patient's Full Name], who was under your care at your esteemed medical facility in Maine. I am aware of the importance of these records in maintaining a comprehensive medical history, and I would greatly appreciate your assistance in obtaining them. Patient Details: Full Name: [Patient's Full Name] Date of Birth: [Patient's Date of Birth] Address: [Patient's Address] Phone Number: [Patient's Phone Number] Below, I have provided the relevant details for the requested medical records: 1. Date Range: Please include all medical records available from [Start Date] to [End Date]. If possible, I kindly request that you provide records dating back to [Patient's Initial Visit Date] in order to establish a comprehensive medical history. 2. Specific Records: Kindly include all records related to diagnoses, assessments, medical history, treatments, medications prescribed, laboratory test results, X-rays, scans, surgical reports, referrals, and any other relevant details that have been documented during [Patient's Full Name]'s time under your care. 3. Method of Delivery: Please specify if the records can be delivered in electronic format or if I should collect them from your office in person. If electronic delivery is possible, kindly provide them in a secure and encrypted format to ensure patient privacy is maintained. 4. Authorization: I authorize the release of these medical records in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and any other applicable laws or regulations. If any fees associated with this request are required, please inform me in advance. 5. Timeframe: While I understand the process may take some time, I kindly request that you fulfill this request within 30 days from the date of this letter. Should there be any delays or difficulties in processing this request, please notify me promptly. Please find enclosed a signed Medical Records Release Form, as required by your facility. Should any additional documentation be necessary, kindly inform me as soon as possible, and I will gladly provide it. If you have any questions or require additional information, please do not hesitate to contact me at [Your Contact Number] or via email at [Your Email Address]. Thank you for considering this request, and I greatly appreciate your attention to detail and prompt assistance in this matter. Your cooperation is vital in ensuring the continuity of [Patient's Full Name]'s healthcare. I look forward to receiving the requested medical records soon. Sincerely, [Your Full Name] [Your Address] [City, State, ZIP] [Your Contact Number] [Your Email Address] Enclosure: — Medical Records Release Form