New York Sample Letter for Request for Medical Records

• Category: Letters - Nonlegal - Requests
• State: Multi-State
• Control #: US-0546LR
• Format: Word; Rich Text

Description

Sample Letter for Request for Medical Records Subject: Request for Medical Records — [Patient's Name] [Your Name] [Your Address] [City, State, ZIP] [Contact Number] [Email Address] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Dear [Medical Provider's Name], I hope this letter finds you in good health. I am writing to request a copy of the medical records of [Patient's Name], who received medical care at your esteemed facility. As authorized by the Health Insurance Portability and Accountability Act (HIPAA) and the State of New York's laws regarding patient access to medical records, I kindly request your assistance in providing these records for review and continuity of care purposes. Patient Details: Full Name: [Patient's Name] Date of Birth: [Patient's DOB] Social Security Number: [Patient's SSN] Address: [Patient's Address] Contact Number: [Patient's Contact Number] Email Address: [Patient's Email Address] Enclosed with this letter, you will find a signed and dated Authorization for Release of Medical Records form. This authorization demonstrates the patient's consent for the disclosure of their medical information to the requesting party, as required by HIPAA and New York State laws. Please note the following key details related to this request: 1. Reason for Request: [Provide the reason for the request, such as the need for a second opinion, continuation of care, or personal records] 2. Specific Records Requested: [Outline the specific medical records or documents required, such as office visit notes, laboratory results, imaging reports, surgical records, etc.] 3. Dates of Treatment: [Specify the approximate dates or timeframe of the medical treatment received by the patient] 4. Means of Delivery: [Indicate whether you prefer receiving the records via mail, secure email, or any other secure electronic method] 5. Method of Payment: [Specify if there are any applicable fees associated with obtaining the records, and provide instructions for payment] 6. Requested Timeline: [State your preferred timeline for receiving the requested medical records; for example, within 30 days of receiving this letter] I understand that the retrieval and preparation of medical records can take time, ND I appreciate your attention to this matter. If there are any anticipated delays or challenges in fulfilling this request, kindly inform me as soon as possible. Please feel free to contact me at [Your Contact Number] or via email at [Your Email Address] for any questions, concerns, or clarification regarding this request. Your prompt response in this regard will be highly appreciated. Thank you for your attention and cooperation in providing the requested medical records within the specified timeline. I look forward to receiving the records and ensuring the best possible care for [Patient's Name]. Sincerely, [Your Name]

Subject: Request for Medical Records — [Patient's Name] [Your Name] [Your Address] [City, State, ZIP] [Contact Number] [Email Address] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Dear [Medical Provider's Name], I hope this letter finds you in good health. I am writing to request a copy of the medical records of [Patient's Name], who received medical care at your esteemed facility. As authorized by the Health Insurance Portability and Accountability Act (HIPAA) and the State of New York's laws regarding patient access to medical records, I kindly request your assistance in providing these records for review and continuity of care purposes. Patient Details: Full Name: [Patient's Name] Date of Birth: [Patient's DOB] Social Security Number: [Patient's SSN] Address: [Patient's Address] Contact Number: [Patient's Contact Number] Email Address: [Patient's Email Address] Enclosed with this letter, you will find a signed and dated Authorization for Release of Medical Records form. This authorization demonstrates the patient's consent for the disclosure of their medical information to the requesting party, as required by HIPAA and New York State laws. Please note the following key details related to this request: 1. Reason for Request: [Provide the reason for the request, such as the need for a second opinion, continuation of care, or personal records] 2. Specific Records Requested: [Outline the specific medical records or documents required, such as office visit notes, laboratory results, imaging reports, surgical records, etc.] 3. Dates of Treatment: [Specify the approximate dates or timeframe of the medical treatment received by the patient] 4. Means of Delivery: [Indicate whether you prefer receiving the records via mail, secure email, or any other secure electronic method] 5. Method of Payment: [Specify if there are any applicable fees associated with obtaining the records, and provide instructions for payment] 6. Requested Timeline: [State your preferred timeline for receiving the requested medical records; for example, within 30 days of receiving this letter] I understand that the retrieval and preparation of medical records can take time, ND I appreciate your attention to this matter. If there are any anticipated delays or challenges in fulfilling this request, kindly inform me as soon as possible. Please feel free to contact me at [Your Contact Number] or via email at [Your Email Address] for any questions, concerns, or clarification regarding this request. Your prompt response in this regard will be highly appreciated. Thank you for your attention and cooperation in providing the requested medical records within the specified timeline. I look forward to receiving the records and ensuring the best possible care for [Patient's Name]. Sincerely, [Your Name]