New Mexico 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 Code] [Email Address] [Phone Number] [Date] [Medical Facility Name] [Address] [City, State, ZIP Code] Subject: Request for Patient Medical Records Dear [Medical Facility Name], I hope this letter finds you well. I am writing to request a copy of my medical records for the purpose of [state the reason, such as personal records or continuing care with a new healthcare provider]. I have been a patient at your esteemed facility and received medical services between [mention the dates of treatment, if known]. To ensure accurate retrieval of my medical records, I am providing the following information: Patient Name: [Full Name] Date of Birth: [MM/DD/YYY] Social Security Number: [Last 4 Digits] Address at the Time of Treatment: [Full Address] Please find enclosed a signed HIPAA (Health Insurance Portability and Accountability Act) Authorization Form, permitting the release of my medical records to the address mentioned above. If there are any additional forms or fees required for the record retrieval, please inform me at your earliest convenience. I understand that there may be a processing period involved, and I kindly request you to complete this request within the legally permitted timeframe. It is important to note that these records are vital for my ongoing medical care and to maintain continuity throughout my healthcare journey. If for any reason my request cannot be fulfilled within the specified time frame or if there are any concerns regarding this request, kindly inform me promptly in writing or via email provided above. Thank you for your prompt attention to this matter. I look forward to receiving my medical records from your facility. Your professional assistance in this regard is greatly appreciated. Should you require any further information or if there are any questions, please do not hesitate to contact me directly. I can be reached at the phone number or email address mentioned above. Thank you for your kind cooperation. Sincerely, [Your Name] Enclosure: HIPAA Authorization Form

[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Medical Facility Name] [Address] [City, State, ZIP Code] Subject: Request for Patient Medical Records Dear [Medical Facility Name], I hope this letter finds you well. I am writing to request a copy of my medical records for the purpose of [state the reason, such as personal records or continuing care with a new healthcare provider]. I have been a patient at your esteemed facility and received medical services between [mention the dates of treatment, if known]. To ensure accurate retrieval of my medical records, I am providing the following information: Patient Name: [Full Name] Date of Birth: [MM/DD/YYY] Social Security Number: [Last 4 Digits] Address at the Time of Treatment: [Full Address] Please find enclosed a signed HIPAA (Health Insurance Portability and Accountability Act) Authorization Form, permitting the release of my medical records to the address mentioned above. If there are any additional forms or fees required for the record retrieval, please inform me at your earliest convenience. I understand that there may be a processing period involved, and I kindly request you to complete this request within the legally permitted timeframe. It is important to note that these records are vital for my ongoing medical care and to maintain continuity throughout my healthcare journey. If for any reason my request cannot be fulfilled within the specified time frame or if there are any concerns regarding this request, kindly inform me promptly in writing or via email provided above. Thank you for your prompt attention to this matter. I look forward to receiving my medical records from your facility. Your professional assistance in this regard is greatly appreciated. Should you require any further information or if there are any questions, please do not hesitate to contact me directly. I can be reached at the phone number or email address mentioned above. Thank you for your kind cooperation. Sincerely, [Your Name] Enclosure: HIPAA Authorization Form