Vermont 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 — Authorization for Release of Information Dear [Medical Provider's Name], I am writing to formally request copies of my medical records, in accordance with the Vermont state laws pertaining to patient rights and access to medical information. I sincerely appreciate your attention to this matter and kindly request your prompt assistance in providing the following documents: 1. Authorization for Release of Information: Please find attached a completed and signed Authorization for Release of Medical Information form, authorizing the disclosure of my medical records. This form outlines the specific types of medical information I am requesting and grants permission for their release. 2. Identification Documents: In compliance with the applicable regulations, I have enclosed a copy of my valid photo identification (such as a driver's license or passport) as proof of identity. 3. Description of Medical Records: I kindly request the following specific medical records, as applicable: — Comprehensive Medical History: Please include all records related to my past and current medical conditions, diagnoses, and procedures. This should encompass doctors’ notes, test results, consultation reports, treatment plans, and any correspondence relating to my healthcare. — Laboratory and Radiology Reports: Please provide copies of all laboratory test results, diagnostic imaging reports (e.g., X-rays, MRIs, CT scans), and any other related records. — Medication and Prescription History: I would appreciate a comprehensive record of all medications I have been prescribed, including the dosage, duration, and any changes made throughout my treatment. — Surgical Records: If applicable, kindly provide all surgical reports, including details of the procedures performed, anesthesia records, Ireland post-operative documentation, and any associated follow-up care. — Specialist Consultations: Please include any documentation pertaining to my visits and consultations with specialists, including referral letters, reports, and treatment recommendations. — Mental Health and Therapy Records: If applicable, kindly include any records relating to mental health assessments, therapy sessions, or psychiatric evaluations. 4. Preferred Delivery Method: Please advise on your preferred method of delivering the requested medical records, such as secure electronic transmission or physical copies by mail. If any fees associated with copying or administration apply, kindly provide an estimate and specify the acceptable forms of payment. 5. Contact Information: For any questions or further correspondence regarding this request, please feel free to contact me as indicated below: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Address: [Your Complete Mailing Address] — Phone Number: [Your Contact Number— - Email Address: [Your Email Address] I deeply appreciate your attention and assistance in fulfilling this request, which is crucial for ongoing medical care and the well-being of my health. I trust in your professionalism and commitment to patient care. Thank you for your prompt attention to this matter. Sincerely, [Your Full Name]

Subject: Request for Medical Records — Authorization for Release of Information Dear [Medical Provider's Name], I am writing to formally request copies of my medical records, in accordance with the Vermont state laws pertaining to patient rights and access to medical information. I sincerely appreciate your attention to this matter and kindly request your prompt assistance in providing the following documents: 1. Authorization for Release of Information: Please find attached a completed and signed Authorization for Release of Medical Information form, authorizing the disclosure of my medical records. This form outlines the specific types of medical information I am requesting and grants permission for their release. 2. Identification Documents: In compliance with the applicable regulations, I have enclosed a copy of my valid photo identification (such as a driver's license or passport) as proof of identity. 3. Description of Medical Records: I kindly request the following specific medical records, as applicable: — Comprehensive Medical History: Please include all records related to my past and current medical conditions, diagnoses, and procedures. This should encompass doctors’ notes, test results, consultation reports, treatment plans, and any correspondence relating to my healthcare. — Laboratory and Radiology Reports: Please provide copies of all laboratory test results, diagnostic imaging reports (e.g., X-rays, MRIs, CT scans), and any other related records. — Medication and Prescription History: I would appreciate a comprehensive record of all medications I have been prescribed, including the dosage, duration, and any changes made throughout my treatment. — Surgical Records: If applicable, kindly provide all surgical reports, including details of the procedures performed, anesthesia records, Ireland post-operative documentation, and any associated follow-up care. — Specialist Consultations: Please include any documentation pertaining to my visits and consultations with specialists, including referral letters, reports, and treatment recommendations. — Mental Health and Therapy Records: If applicable, kindly include any records relating to mental health assessments, therapy sessions, or psychiatric evaluations. 4. Preferred Delivery Method: Please advise on your preferred method of delivering the requested medical records, such as secure electronic transmission or physical copies by mail. If any fees associated with copying or administration apply, kindly provide an estimate and specify the acceptable forms of payment. 5. Contact Information: For any questions or further correspondence regarding this request, please feel free to contact me as indicated below: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Address: [Your Complete Mailing Address] — Phone Number: [Your Contact Number— - Email Address: [Your Email Address] I deeply appreciate your attention and assistance in fulfilling this request, which is crucial for ongoing medical care and the well-being of my health. I trust in your professionalism and commitment to patient care. Thank you for your prompt attention to this matter. Sincerely, [Your Full Name]