New Jersey 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] [Email Address] [Phone Number] [Date] [Responsible Authority] [Medical Facility Name] [Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Responsible Authority], I am writing to formally request access to my medical records, as permitted under the Health Insurance Portability and Accountability Act (HIPAA) and the New Jersey state laws pertaining to medical records access. I am a patient at your esteemed facility and would like to obtain a complete copy of my medical records for personal reference and to share with my new healthcare provider. To assist you in processing my request efficiently, I have provided relevant details below: 1. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number: [Patient's SSN] — Medical Record Number (if applicable): [Patient's MAN] 2. Date Range of Records Requested: [Specify the range of dates or years] 3. Types of Medical Records Requested: — Demographic information and personal history — Consultation notes and progress reports — Diagnostic test results (e.g., lab reports, radiology imaging) — Surgical and operative reports (if applicable) — Hospitalization records (including discharge summaries) — Medication and prescriptiohistoryor— - Immunization records — Any other relevant documents within the specified date range 4. Preferred Format and Delivery Method: As per my preference, I kindly request that you provide the records in electronic format (if available) on a secure and password-protected CD, USB drive, or via email to the provided email address. If electronic format is not possible, I am willing to receive a hard copy of the records through postal mail. 5. Purpose of Request: I am transitioning to a new healthcare provider, and having my complete medical history will enable them to provide me with optimal and continuous care. Additionally, having access to my medical records empowers me to make informed decisions regarding my healthcare. 6. Authorization and Verification: Enclosed with this letter, please find a copy of my signed and dated Patient Authorization of Release of Medical Information form, as required by HIPAA guidelines. Please use this form to verify my identity and authorize the release of my medical records. 7. Fees and Payment: As per the New Jersey Administrative Code, I understand that I may be responsible for reasonable costs associated with reproducing and delivering the medical records. However, before proceeding, I request that you provide me with a detailed itemized estimate of any applicable fees. Payment will be made promptly upon receiving the estimate, and I kindly request that you inform me of your preferred payment method. I appreciate your prompt attention to this matter and assure you that I will comply with any additional procedures necessary to fulfill my request. Please feel free to contact me at [Phone Number] or [Email Address] if you require any further information or have any questions regarding my request. Thank you for your cooperation, and I look forward to receiving my medical records within a reasonable period of time, as defined by the New Jersey state regulations. Sincerely, [Your Full Name] [Patient's Signature (if mailing)] [Patient's Date of Birth]

[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Responsible Authority] [Medical Facility Name] [Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Responsible Authority], I am writing to formally request access to my medical records, as permitted under the Health Insurance Portability and Accountability Act (HIPAA) and the New Jersey state laws pertaining to medical records access. I am a patient at your esteemed facility and would like to obtain a complete copy of my medical records for personal reference and to share with my new healthcare provider. To assist you in processing my request efficiently, I have provided relevant details below: 1. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number: [Patient's SSN] — Medical Record Number (if applicable): [Patient's MAN] 2. Date Range of Records Requested: [Specify the range of dates or years] 3. Types of Medical Records Requested: — Demographic information and personal history — Consultation notes and progress reports — Diagnostic test results (e.g., lab reports, radiology imaging) — Surgical and operative reports (if applicable) — Hospitalization records (including discharge summaries) — Medication and prescriptiohistoryor— - Immunization records — Any other relevant documents within the specified date range 4. Preferred Format and Delivery Method: As per my preference, I kindly request that you provide the records in electronic format (if available) on a secure and password-protected CD, USB drive, or via email to the provided email address. If electronic format is not possible, I am willing to receive a hard copy of the records through postal mail. 5. Purpose of Request: I am transitioning to a new healthcare provider, and having my complete medical history will enable them to provide me with optimal and continuous care. Additionally, having access to my medical records empowers me to make informed decisions regarding my healthcare. 6. Authorization and Verification: Enclosed with this letter, please find a copy of my signed and dated Patient Authorization of Release of Medical Information form, as required by HIPAA guidelines. Please use this form to verify my identity and authorize the release of my medical records. 7. Fees and Payment: As per the New Jersey Administrative Code, I understand that I may be responsible for reasonable costs associated with reproducing and delivering the medical records. However, before proceeding, I request that you provide me with a detailed itemized estimate of any applicable fees. Payment will be made promptly upon receiving the estimate, and I kindly request that you inform me of your preferred payment method. I appreciate your prompt attention to this matter and assure you that I will comply with any additional procedures necessary to fulfill my request. Please feel free to contact me at [Phone Number] or [Email Address] if you require any further information or have any questions regarding my request. Thank you for your cooperation, and I look forward to receiving my medical records within a reasonable period of time, as defined by the New Jersey state regulations. Sincerely, [Your Full Name] [Patient's Signature (if mailing)] [Patient's Date of Birth]