Michigan 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. [Your Name] [Your Address] [City, State, ZIP] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Request for Release of Patient Medical Records Dear [Medical Provider's Name], I am writing to formally request the release of my medical records as allowed by applicable state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA). I appreciate your prompt attention to this matter. Patient Information: — Patient's Full Name: [Patient's Full Name] — Date of Birth: [Patient's Date of Birth] — Social Security Number (SSN): [Patient's SSN] — Date of Admission: [Date of Admission] — Billing Account Number (if available): [Billing Account Number] Reason for Request: [Explain the purpose or reason for requesting the medical records. For instance, it can be for personal reference, continuation of care, a second opinion, legal purposes, or insurance claims.] Authorization: I authorize the release of the following medical records pertaining to my treatment at your facility: — Complete medical history, including but not limited to consultations, progress notes, treatment plans, laboratory results, diagnostic tests, operative reports, and discharge summaries. — Radiology reports and images (X-rays, CT scans, MRI scans, etc.) — Pathology reports, including biopsy results, if applicable. — Immunization records— - Medication history and prescription records. — Mental health records (if applicable). — Insurance and billing records (if applicable). Please note that this request includes both paper-based and electronic health records, including any records stored in electronic health record systems or other digital formats. Delivery of Records: If possible, I would prefer to receive the requested medical records in an electronic format, such as a secure PDF file or through a secure online portal. However, if it is not feasible, please provide them in a paper format. To cover any associated costs, please let me know if there are any fees for copying or transferring the medical records. Please ensure that the records are delivered within the timeframes set forth by Michigan state law, which requires medical providers to respond to such requests within 30 days. Enclosed with this letter, you will find a prepaid envelope to facilitate the expedited delivery of the records. Contact Information: Should you require any additional information or have any questions regarding this request, please do not hesitate to contact me at the phone number or email address provided below. [Your Phone Number] [Your Email Address] Thank you for your attention to this matter. Your cooperation is greatly appreciated. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Request for Release of Patient Medical Records Dear [Medical Provider's Name], I am writing to formally request the release of my medical records as allowed by applicable state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA). I appreciate your prompt attention to this matter. Patient Information: — Patient's Full Name: [Patient's Full Name] — Date of Birth: [Patient's Date of Birth] — Social Security Number (SSN): [Patient's SSN] — Date of Admission: [Date of Admission] — Billing Account Number (if available): [Billing Account Number] Reason for Request: [Explain the purpose or reason for requesting the medical records. For instance, it can be for personal reference, continuation of care, a second opinion, legal purposes, or insurance claims.] Authorization: I authorize the release of the following medical records pertaining to my treatment at your facility: — Complete medical history, including but not limited to consultations, progress notes, treatment plans, laboratory results, diagnostic tests, operative reports, and discharge summaries. — Radiology reports and images (X-rays, CT scans, MRI scans, etc.) — Pathology reports, including biopsy results, if applicable. — Immunization records— - Medication history and prescription records. — Mental health records (if applicable). — Insurance and billing records (if applicable). Please note that this request includes both paper-based and electronic health records, including any records stored in electronic health record systems or other digital formats. Delivery of Records: If possible, I would prefer to receive the requested medical records in an electronic format, such as a secure PDF file or through a secure online portal. However, if it is not feasible, please provide them in a paper format. To cover any associated costs, please let me know if there are any fees for copying or transferring the medical records. Please ensure that the records are delivered within the timeframes set forth by Michigan state law, which requires medical providers to respond to such requests within 30 days. Enclosed with this letter, you will find a prepaid envelope to facilitate the expedited delivery of the records. Contact Information: Should you require any additional information or have any questions regarding this request, please do not hesitate to contact me at the phone number or email address provided below. [Your Phone Number] [Your Email Address] Thank you for your attention to this matter. Your cooperation is greatly appreciated. Sincerely, [Your Name]