North Carolina 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 Release of Patient Medical Records — [Patient Name], [Date of Birth] [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Name of Medical Institution] [Attn: Medical Records Dept.] [Address] [City, State, ZIP Code] Re: Release of Patient Medical Records — [Patient Name], [Date of Birth], [Medical Record Number] Dear Sir/Madam, I am writing to formally request the release of comprehensive medical records for [Patient Name], born on [Date of Birth], and assigned with the medical record number [Medical Record Number]. I require these records for personal reference and to ensure the continuity of healthcare for the patient. Please find enclosed a signed Authorization for Release of Medical Records form, as required by applicable laws and regulations within North Carolina. This form grants permission to release all relevant medical information related to the patient's diagnoses, treatments, medications, laboratory results, surgical history, imaging reports, and any other pertinent health data. To facilitate the process, it would be greatly appreciated if you could comply with the following requisites: 1. Complete Medical Records: Please ensure that all the medical records, including but not limited to physician notes, progress reports, consultation summaries, and discharge summaries, are included. 2. Imaging Reports: Kindly provide all radiology and imaging reports, such as X-rays, CT scans, MRI scans, ultrasounds, and mammograms, along with any accompanying interpretations. 3. Laboratory Results: Please include all pertinent laboratory test results, including blood tests, urinalysis, pathology reports, microbiology reports, and any other relevant diagnostic tests. 4. Surgical History: If applicable, kindly provide detailed surgical notes, operative reports, anesthesia records, and PRE/post-operative evaluations. 5. All Specialist Consultations: In cases where the patient has sought consultations from specialists, please ensure their related notes, correspondence, and reports are included. 6. Any Additional Relevant Documents: If there are any relevant documents or information that could contribute to a comprehensive overview of the patient's medical history, please include them along with the records. I understand that there may be fees associated with processing this request, as permitted under North Carolina law, and I am willing to cover such expenses. If you could provide an estimate of the fees involved, I will arrange for timely payment to ensure prompt fulfillment of this request. Kindly acknowledge receipt of this request within five business days and inform me of any further requirements or documentation needed to process it smoothly. Additionally, please inform me of the expected timeframe for the processing and release of the requested medical records. Thank you for your attention to this matter, and I look forward to receiving the requested medical records within a reasonable timeframe. Sincerely, [Your Name]

Subject: Request for Release of Patient Medical Records — [Patient Name], [Date of Birth] [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Name of Medical Institution] [Attn: Medical Records Dept.] [Address] [City, State, ZIP Code] Re: Release of Patient Medical Records — [Patient Name], [Date of Birth], [Medical Record Number] Dear Sir/Madam, I am writing to formally request the release of comprehensive medical records for [Patient Name], born on [Date of Birth], and assigned with the medical record number [Medical Record Number]. I require these records for personal reference and to ensure the continuity of healthcare for the patient. Please find enclosed a signed Authorization for Release of Medical Records form, as required by applicable laws and regulations within North Carolina. This form grants permission to release all relevant medical information related to the patient's diagnoses, treatments, medications, laboratory results, surgical history, imaging reports, and any other pertinent health data. To facilitate the process, it would be greatly appreciated if you could comply with the following requisites: 1. Complete Medical Records: Please ensure that all the medical records, including but not limited to physician notes, progress reports, consultation summaries, and discharge summaries, are included. 2. Imaging Reports: Kindly provide all radiology and imaging reports, such as X-rays, CT scans, MRI scans, ultrasounds, and mammograms, along with any accompanying interpretations. 3. Laboratory Results: Please include all pertinent laboratory test results, including blood tests, urinalysis, pathology reports, microbiology reports, and any other relevant diagnostic tests. 4. Surgical History: If applicable, kindly provide detailed surgical notes, operative reports, anesthesia records, and PRE/post-operative evaluations. 5. All Specialist Consultations: In cases where the patient has sought consultations from specialists, please ensure their related notes, correspondence, and reports are included. 6. Any Additional Relevant Documents: If there are any relevant documents or information that could contribute to a comprehensive overview of the patient's medical history, please include them along with the records. I understand that there may be fees associated with processing this request, as permitted under North Carolina law, and I am willing to cover such expenses. If you could provide an estimate of the fees involved, I will arrange for timely payment to ensure prompt fulfillment of this request. Kindly acknowledge receipt of this request within five business days and inform me of any further requirements or documentation needed to process it smoothly. Additionally, please inform me of the expected timeframe for the processing and release of the requested medical records. Thank you for your attention to this matter, and I look forward to receiving the requested medical records within a reasonable timeframe. Sincerely, [Your Name]