Ohio 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. Sample Letter for Request for Patient Medical Records in Ohio Subject: Request for Release of Patient's Medical Records Dear [Healthcare Provider/Patient Records Department], I am writing to request access to [Patient's Full Name]'s medical records as permitted by HIPAA and state law. I am [Patient's Legal Representative/Parent/Guardian] and have been authorized to obtain these records on behalf of the patient. Patient's Information: Full Name: [Patient's Full Name] Date of Birth: [Patient's Date of Birth] Gender: [Patient's Gender] Address: [Patient's Current Address] Phone Number: [Patient's Contact Number] Primary Care Physician (if applicable): Name: [Primary Care Physician's Full Name] Address: [Primary Care Physician's Address] Phone Number: [Primary Care Physician's Contact Number] Requested Medical Records: Please provide copies of the following medical records for the specified time frame [start date] to [end date]: 1. Doctor's notes 2. Consultation reports 3. Laboratory test results (including blood tests, X-rays, CAT scans, MRIs, etc.) 4. Treatment and medication records 5. Surgical reports, if applicable 6. Emergency room records, if applicable 7. Specialist reports, if applicable 8. Mental health records, if applicable Purpose of Request: The purpose of this request is [to continue ongoing medical care/to seek a second opinion/to fulfill legal or insurance requirements/to better understand the patient's medical history/etc.]. Patient Consent: I have included a signed authorization form from the patient, [Patient's Full Name], granting permission for the release of their medical records. Please find the form enclosed with this letter. Delivery Method and Address: We kindly request that the medical records be delivered in electronic format (if available) or by mail to the following address: [Recipient's Name] [Recipient's Full Address] [City, State, Zip Code] Please note that if there are any charges associated with processing this request, please inform me in advance or enclose an invoice with the records. Should you have any questions or require further information, please do not hesitate to contact me at [Contact Number] or via email at [Email Address]. Thank you for your prompt attention to this matter. We appreciate your cooperation in providing the requested medical records. Sincerely, [Your Full Name] [Your Relation to the Patient]

Sample Letter for Request for Patient Medical Records in Ohio Subject: Request for Release of Patient's Medical Records Dear [Healthcare Provider/Patient Records Department], I am writing to request access to [Patient's Full Name]'s medical records as permitted by HIPAA and state law. I am [Patient's Legal Representative/Parent/Guardian] and have been authorized to obtain these records on behalf of the patient. Patient's Information: Full Name: [Patient's Full Name] Date of Birth: [Patient's Date of Birth] Gender: [Patient's Gender] Address: [Patient's Current Address] Phone Number: [Patient's Contact Number] Primary Care Physician (if applicable): Name: [Primary Care Physician's Full Name] Address: [Primary Care Physician's Address] Phone Number: [Primary Care Physician's Contact Number] Requested Medical Records: Please provide copies of the following medical records for the specified time frame [start date] to [end date]: 1. Doctor's notes 2. Consultation reports 3. Laboratory test results (including blood tests, X-rays, CAT scans, MRIs, etc.) 4. Treatment and medication records 5. Surgical reports, if applicable 6. Emergency room records, if applicable 7. Specialist reports, if applicable 8. Mental health records, if applicable Purpose of Request: The purpose of this request is [to continue ongoing medical care/to seek a second opinion/to fulfill legal or insurance requirements/to better understand the patient's medical history/etc.]. Patient Consent: I have included a signed authorization form from the patient, [Patient's Full Name], granting permission for the release of their medical records. Please find the form enclosed with this letter. Delivery Method and Address: We kindly request that the medical records be delivered in electronic format (if available) or by mail to the following address: [Recipient's Name] [Recipient's Full Address] [City, State, Zip Code] Please note that if there are any charges associated with processing this request, please inform me in advance or enclose an invoice with the records. Should you have any questions or require further information, please do not hesitate to contact me at [Contact Number] or via email at [Email Address]. Thank you for your prompt attention to this matter. We appreciate your cooperation in providing the requested medical records. Sincerely, [Your Full Name] [Your Relation to the Patient]