West Virginia 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. [Your Name] [Your Address] [City, State, Zip Code] [Phone Number] [Email Address] [Date] [Recipient's Name] [Recipient's Position] [Medical Facility Name] [Address] [City, State, Zip Code] Subject: Request for Patient Medical Records Dear [Recipient's Name], I hope this letter finds you in good health and high spirits. I am writing to request the release of my medical records from [Medical Facility Name]. As a resident of West Virginia, I understand the importance of maintaining my personal health history for legal and personal reasons. I was a patient at [Medical Facility Name] from [specific dates if known] and was treated by [Primary Doctor's Name]. Along with my identification documents enclosed with this letter, I hereby authorize the release of my medical records, including but not limited to: 1. Medical History: Please include all consultations, diagnoses, treatment plans, prescriptions, and surgical procedures that have been recorded during my visits to the facility. 2. Laboratory Reports: Kindly provide all laboratory reports, including blood tests, urine tests, biopsies, and any other relevant diagnostic tests conducted during my treatment. 3. Imaging Studies: I request copies of all imaging studies, such as X-rays, MRIs, CT scans, ultrasounds, or any other radiological tests performed as part of my medical evaluation. 4. Progress Notes: Please include all progress notes, medical observations, and any communication exchanged between healthcare professionals involved in my care. 5. Referral Reports: If applicable, kindly provide any referral reports received or generated by [Medical Facility Name] for consultations or treatments provided by other healthcare providers. 6. Correspondence and Corresponding Test Results: I request copies of any correspondence and relevant test results pertaining to my healthcare, including communications with other healthcare professionals, insurance companies, or legal entities. To expedite the process, I have attached a signed Consent for Release of Medical Records form, as required by West Virginia law. I affirm that all the information provided in this letter is true and accurate to the best of my knowledge. If there are any fees associated with obtaining these records, please inform me in advance. I am willing to cover reasonable costs for this service as outlined by West Virginia regulations. I kindly request that you acknowledge receipt of this letter within 10 business days and provide me with an estimated timeframe for when I can expect the requested medical records. If additional information or documentation is required, please inform me promptly so that I may provide it. Thank you for your attention to this matter. Your assistance in providing my medical records will greatly contribute to the continuity of my healthcare management. If you have any questions or require further clarification, please do not hesitate to contact me at [Phone Number] or [Email Address]. I look forward to your prompt response and cooperation. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, Zip Code] [Phone Number] [Email Address] [Date] [Recipient's Name] [Recipient's Position] [Medical Facility Name] [Address] [City, State, Zip Code] Subject: Request for Patient Medical Records Dear [Recipient's Name], I hope this letter finds you in good health and high spirits. I am writing to request the release of my medical records from [Medical Facility Name]. As a resident of West Virginia, I understand the importance of maintaining my personal health history for legal and personal reasons. I was a patient at [Medical Facility Name] from [specific dates if known] and was treated by [Primary Doctor's Name]. Along with my identification documents enclosed with this letter, I hereby authorize the release of my medical records, including but not limited to: 1. Medical History: Please include all consultations, diagnoses, treatment plans, prescriptions, and surgical procedures that have been recorded during my visits to the facility. 2. Laboratory Reports: Kindly provide all laboratory reports, including blood tests, urine tests, biopsies, and any other relevant diagnostic tests conducted during my treatment. 3. Imaging Studies: I request copies of all imaging studies, such as X-rays, MRIs, CT scans, ultrasounds, or any other radiological tests performed as part of my medical evaluation. 4. Progress Notes: Please include all progress notes, medical observations, and any communication exchanged between healthcare professionals involved in my care. 5. Referral Reports: If applicable, kindly provide any referral reports received or generated by [Medical Facility Name] for consultations or treatments provided by other healthcare providers. 6. Correspondence and Corresponding Test Results: I request copies of any correspondence and relevant test results pertaining to my healthcare, including communications with other healthcare professionals, insurance companies, or legal entities. To expedite the process, I have attached a signed Consent for Release of Medical Records form, as required by West Virginia law. I affirm that all the information provided in this letter is true and accurate to the best of my knowledge. If there are any fees associated with obtaining these records, please inform me in advance. I am willing to cover reasonable costs for this service as outlined by West Virginia regulations. I kindly request that you acknowledge receipt of this letter within 10 business days and provide me with an estimated timeframe for when I can expect the requested medical records. If additional information or documentation is required, please inform me promptly so that I may provide it. Thank you for your attention to this matter. Your assistance in providing my medical records will greatly contribute to the continuity of my healthcare management. If you have any questions or require further clarification, please do not hesitate to contact me at [Phone Number] or [Email Address]. I look forward to your prompt response and cooperation. Sincerely, [Your Name]