Mississippi 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 — Mississippi Dear [Healthcare Provider/Patient Records Department], I hope this letter finds you well. I am writing to firm idly request the patient medical records of [Patient's Full Name] as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Mississippi state law. As an authorized representative, legal guardian, or an individual approved by the patient, I kindly ask for the complete medical records pertaining to [Patient's Full Name]. The purpose of this request is to ensure continuity of care, facilitate a second medical opinion, or for personal records management. Please find below the relevant details required for processing this request: 1. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number (if available): [Patient's SSN] — Address: [Patient's Current Address— - Phone Number: [Patient's Contact Number] 2. Requested Medical Records: — All medical records, including but not limited to: — Doctor notes, diagnosis, and treatment plans — Laboratory test results and imaging studies — Summaries of hospital visit— - Surgical records and procedures — Medication history and prescription— - Allergies and adverse reactions — Mental health assessments and therapy notes — Immunization record— - Any additional relevant documentation 3. Purpose of Request: — [Specify purpose, e.g., continued care with a new healthcare provider, personal records, insurance claim, legal proceedings, etc.] 4. desired Delivery Method: — Please specify the preferred delivery method for the medical records. Options include: — Mail (postage included— - Email (encrypted or password-protected, if possible) — Secure online portaaccesses— - In-person pickup 5. Documentation of Authorization: — Please find attached the necessary documents indicating my authorization to request and receive the patient medical records. [Attach completed HIPAA release form or legal documentation, if applicable.] 6. Fee/Payment: — Kindly inform me of any applicable fees for duplicating and providing the medical records. If required, I am prepared to remit payment in advance. Please advise me of the payment method accepted. 7. Timeframe: — As required by federal and state regulations, please provide the requested medical records within 30 days of receiving this letter. If circumstances prohibit the timely release, please inform me in writing with an explanation and an estimated timeline. I understand the importance of maintaining patient confidentiality and trust. Therefore, I assure you that all received medical records will be treated with the utmost confidentiality and used solely for the stated purpose. Should you require any further information or have any questions, please do not hesitate to contact me at [Your Contact Number] or via email at [Your Email Address]. I appreciate your prompt attention to this matter. Thank you for your assistance in advance. Sincerely, [Your Name] [Your Address] [City, State, ZIP] [Your Contact Number] [Your Email Address]

Subject: Request for Patient Medical Records — Mississippi Dear [Healthcare Provider/Patient Records Department], I hope this letter finds you well. I am writing to firm idly request the patient medical records of [Patient's Full Name] as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Mississippi state law. As an authorized representative, legal guardian, or an individual approved by the patient, I kindly ask for the complete medical records pertaining to [Patient's Full Name]. The purpose of this request is to ensure continuity of care, facilitate a second medical opinion, or for personal records management. Please find below the relevant details required for processing this request: 1. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number (if available): [Patient's SSN] — Address: [Patient's Current Address— - Phone Number: [Patient's Contact Number] 2. Requested Medical Records: — All medical records, including but not limited to: — Doctor notes, diagnosis, and treatment plans — Laboratory test results and imaging studies — Summaries of hospital visit— - Surgical records and procedures — Medication history and prescription— - Allergies and adverse reactions — Mental health assessments and therapy notes — Immunization record— - Any additional relevant documentation 3. Purpose of Request: — [Specify purpose, e.g., continued care with a new healthcare provider, personal records, insurance claim, legal proceedings, etc.] 4. desired Delivery Method: — Please specify the preferred delivery method for the medical records. Options include: — Mail (postage included— - Email (encrypted or password-protected, if possible) — Secure online portaaccesses— - In-person pickup 5. Documentation of Authorization: — Please find attached the necessary documents indicating my authorization to request and receive the patient medical records. [Attach completed HIPAA release form or legal documentation, if applicable.] 6. Fee/Payment: — Kindly inform me of any applicable fees for duplicating and providing the medical records. If required, I am prepared to remit payment in advance. Please advise me of the payment method accepted. 7. Timeframe: — As required by federal and state regulations, please provide the requested medical records within 30 days of receiving this letter. If circumstances prohibit the timely release, please inform me in writing with an explanation and an estimated timeline. I understand the importance of maintaining patient confidentiality and trust. Therefore, I assure you that all received medical records will be treated with the utmost confidentiality and used solely for the stated purpose. Should you require any further information or have any questions, please do not hesitate to contact me at [Your Contact Number] or via email at [Your Email Address]. I appreciate your prompt attention to this matter. Thank you for your assistance in advance. Sincerely, [Your Name] [Your Address] [City, State, ZIP] [Your Contact Number] [Your Email Address]