Nebraska 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 — Nebraska Sample Letter [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP Code] Dear [Medical Provider's Name], RE: REQUEST FOR PATIENT MEDICAL RECORDS I am writing to request the release of the medical records pertaining to my medical care at your facility, as allowed by applicable state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA). As an active participant in my healthcare, I believe it is crucial to have access to complete and accurate medical records to ensure ongoing continuity of care and to assist in making informed decisions about my health. Therefore, I kindly ask for the following documents: 1. Complete medical records: This includes all medical files, test results, laboratory reports, diagnostic imaging reports, progress notes, treatment plans, discharge summaries, and any other relevant information regarding my medical care at your facility. 2. Specialist consultations: I request copies of any consultations or referrals made to specialists outside the medical provider's facility. This will assist in ensuring comprehensive treatment and improving the coordination of my healthcare services. 3. Radiology and imaging reports: Please include copies of all radiology and imaging reports, such as X-rays, MRIs, CT scans, ultrasounds, and any accompanying interpretations, to aid in ongoing assessments and follow-ups with other healthcare providers. 4. Lab test results: Kindly provide me with copies of all laboratory test results, including blood tests, biopsies, cultures, pathology reports, and any related interpretations to stay apprised of my medical history and facilitate future medical interventions if necessary. 5. Treatment plans and prescriptions: I would appreciate receiving copies of all treatment plans, prescriptions, medication lists, and dosage instructions prescribed during my visits to aid in accurate record keeping and adherence to prescribed treatments. To comply with applicable state laws and HIPAA guidelines, please inform me of any fees associated with the retrieval, duplication, and delivery of these medical records. I am willing to pay reasonable charges for these services, and I kindly request cost details and payment instructions. Furthermore, I request that my medical records be provided to me within the timeframe mandated by state law or within 30 days of your receipt of this letter, whichever is sooner. If you encounter any challenges fulfilling this request within the specified timeframe, please notify me immediately and provide the reason for the delay. Please note that this request for medical records pertains to myself, [Patient's Full Name], with a date of birth of [Patient's Date of Birth]. Enclosed is a copy of my identification [or any other required supporting documentation] to aid in the identification process and facilitate a prompt release of my medical records. I appreciate your cooperation and prompt attention to this matter. If you have any questions or require further information, please do not hesitate to contact me at the provided contact details. Thank you for your understanding and timely handling of this request. Sincerely, [Your Name]

Subject: Request for Patient Medical Records — Nebraska Sample Letter [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP Code] Dear [Medical Provider's Name], RE: REQUEST FOR PATIENT MEDICAL RECORDS I am writing to request the release of the medical records pertaining to my medical care at your facility, as allowed by applicable state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA). As an active participant in my healthcare, I believe it is crucial to have access to complete and accurate medical records to ensure ongoing continuity of care and to assist in making informed decisions about my health. Therefore, I kindly ask for the following documents: 1. Complete medical records: This includes all medical files, test results, laboratory reports, diagnostic imaging reports, progress notes, treatment plans, discharge summaries, and any other relevant information regarding my medical care at your facility. 2. Specialist consultations: I request copies of any consultations or referrals made to specialists outside the medical provider's facility. This will assist in ensuring comprehensive treatment and improving the coordination of my healthcare services. 3. Radiology and imaging reports: Please include copies of all radiology and imaging reports, such as X-rays, MRIs, CT scans, ultrasounds, and any accompanying interpretations, to aid in ongoing assessments and follow-ups with other healthcare providers. 4. Lab test results: Kindly provide me with copies of all laboratory test results, including blood tests, biopsies, cultures, pathology reports, and any related interpretations to stay apprised of my medical history and facilitate future medical interventions if necessary. 5. Treatment plans and prescriptions: I would appreciate receiving copies of all treatment plans, prescriptions, medication lists, and dosage instructions prescribed during my visits to aid in accurate record keeping and adherence to prescribed treatments. To comply with applicable state laws and HIPAA guidelines, please inform me of any fees associated with the retrieval, duplication, and delivery of these medical records. I am willing to pay reasonable charges for these services, and I kindly request cost details and payment instructions. Furthermore, I request that my medical records be provided to me within the timeframe mandated by state law or within 30 days of your receipt of this letter, whichever is sooner. If you encounter any challenges fulfilling this request within the specified timeframe, please notify me immediately and provide the reason for the delay. Please note that this request for medical records pertains to myself, [Patient's Full Name], with a date of birth of [Patient's Date of Birth]. Enclosed is a copy of my identification [or any other required supporting documentation] to aid in the identification process and facilitate a prompt release of my medical records. I appreciate your cooperation and prompt attention to this matter. If you have any questions or require further information, please do not hesitate to contact me at the provided contact details. Thank you for your understanding and timely handling of this request. Sincerely, [Your Name]