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]
New York Sample Letter for Request for Medical Records
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How to fill out New York Sample Letter For Request For Medical Records?
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I was treated in your office at your facility between fill in dates. I request copies of the following or all health records related to my treatment. Identify records requested, e.g. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals.
If the patient wrote a personal letter requesting records, make sure the following patient information was in the original request:Date of birth.Name.Social Security number.Contact information (address and phone number)Email address.Dates of service and specific records requested (tests, discharge notes, etc.)More items...
If the patient wrote a personal letter requesting records, make sure the following patient information was in the original request:Date of birth.Name.Social Security number.Contact information (address and phone number)Email address.Dates of service and specific records requested (tests, discharge notes, etc.)More items...
The subject line of your request should be "FOIL Request". Please inform me of the cost of providing paper copies of the following records include as much detail about the records as possible, including relevant dates, names, descriptions, etc..
Notice:Use the Open FOIL NY online form: Agency Code.Mail a written request to: Records Access Office.E-mail a written request to: foil@health.ny.gov.Fax a written request to: (518) 486-9144.Submit a request for records in person:
What information should be included in a patient's medical records?The initial health history and physical examination from the doctor.Consultation reports from specialists, as well as any notes.Operative reports / Medical procedure reports.More items...?
Most practices or facilities will ask you to fill out a form to request your medical records. This request form can usually be collected at the office or delivered by fax, postal service, or email. If the office doesn't have a form, you can write a letter to make your request.
I was treated in your office at your facility between fill in dates. I request copies of the following or all health records related to my treatment. Identify records requested, e.g. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals.
