New York 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 — Urgent [Your Name] [Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Healthcare Provider's Name] [Department] [Address] [City, State, ZIP Code] Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to request the medical records for [Patient's Full Name], who was under the care of your esteemed institution. I understand the significance of patient privacy and ensure that the requested information will be used solely for valid purposes related to the patient's healthcare. To assist you in efficiently retrieving the necessary data, I have included the following details regarding the patient: 1. Patient's Full Name: [Full Name] 2. Date of Birth: [Date of Birth] 3. Social Security Number: [Social Security Number] (optional, if available) 4. Health Insurance Provider: [Insurance Provider] 5. Policy Number: [Policy Number] I kindly request the following medical records: 1. Complete medical history, including but not limited to diagnoses, illnesses, treatments, surgeries, and procedures. 2. Laboratory reports, including blood tests, urinalysis, pathology results, etc. 3. Radiology reports, such as X-rays, MRI, CT scan findings, etc. 4. Progress notes and consultation reports from referring physicians or specialists. 5. Prescription medication history, including dosage, frequency, and duration. 6. Immunization records. 7. Any discharge summaries or documentation related to hospital admissions or emergency room visits. Please provide the requested records in a digital format, if possible, to expedite the process. If the records cannot be supplied electronically, please advise me of the necessary steps to obtain the physical copies. As per the federal regulations outlined in HIPAA (Health Insurance Portability and Accountability Act) and the HITCH (Health Information Technology for Economic and Clinical Health) Act, I understand there may be a reasonable fee for the retrieval and duplication of medical records. Kindly inform me of the associated costs, if any, and provide a breakdown of the charges before proceeding. Due to the urgency of the matter, I kindly request your prompt attention to this request. As the records are required for ongoing medical treatment, I would appreciate it if you could process my request within [specify a reasonable timeframe, e.g., ten business days] from the date of this letter. Please feel free to contact me at [Your Phone Number] or [Your Email Address] should you require any additional information or if there are any concerns regarding this request. Thank you in advance for your assistance and cooperation. I eagerly anticipate receiving the requested medical records within the specified timeframe. Sincerely, [Your Full Name] [Patient's Full Name (if different)] [Patient's Date of Birth (if different)] [Relationship to the Patient] (e.g., parent, legal guardian, attorney)

Subject: Request for Patient Medical Records — Urgent [Your Name] [Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Healthcare Provider's Name] [Department] [Address] [City, State, ZIP Code] Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to request the medical records for [Patient's Full Name], who was under the care of your esteemed institution. I understand the significance of patient privacy and ensure that the requested information will be used solely for valid purposes related to the patient's healthcare. To assist you in efficiently retrieving the necessary data, I have included the following details regarding the patient: 1. Patient's Full Name: [Full Name] 2. Date of Birth: [Date of Birth] 3. Social Security Number: [Social Security Number] (optional, if available) 4. Health Insurance Provider: [Insurance Provider] 5. Policy Number: [Policy Number] I kindly request the following medical records: 1. Complete medical history, including but not limited to diagnoses, illnesses, treatments, surgeries, and procedures. 2. Laboratory reports, including blood tests, urinalysis, pathology results, etc. 3. Radiology reports, such as X-rays, MRI, CT scan findings, etc. 4. Progress notes and consultation reports from referring physicians or specialists. 5. Prescription medication history, including dosage, frequency, and duration. 6. Immunization records. 7. Any discharge summaries or documentation related to hospital admissions or emergency room visits. Please provide the requested records in a digital format, if possible, to expedite the process. If the records cannot be supplied electronically, please advise me of the necessary steps to obtain the physical copies. As per the federal regulations outlined in HIPAA (Health Insurance Portability and Accountability Act) and the HITCH (Health Information Technology for Economic and Clinical Health) Act, I understand there may be a reasonable fee for the retrieval and duplication of medical records. Kindly inform me of the associated costs, if any, and provide a breakdown of the charges before proceeding. Due to the urgency of the matter, I kindly request your prompt attention to this request. As the records are required for ongoing medical treatment, I would appreciate it if you could process my request within [specify a reasonable timeframe, e.g., ten business days] from the date of this letter. Please feel free to contact me at [Your Phone Number] or [Your Email Address] should you require any additional information or if there are any concerns regarding this request. Thank you in advance for your assistance and cooperation. I eagerly anticipate receiving the requested medical records within the specified timeframe. Sincerely, [Your Full Name] [Patient's Full Name (if different)] [Patient's Date of Birth (if different)] [Relationship to the Patient] (e.g., parent, legal guardian, attorney)