Chicago Illinois Sample Letter for Request for Patient Medical Records

• Category: Letters - Nonlegal - Medical
• State: Multi-State
• City: Chicago
• 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] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to request the release of my medical records, as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws. I had previously received medical treatment at your esteemed medical facility, and it is essential for me to obtain a copy of my complete medical records for personal reference and to share with my current healthcare providers. Please find below the necessary details to process my request for patient medical records: 1. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number (optional): [Patient's SSN] — Address at the time of treatment: [Patient's Address during treatment] — Phone Number: [Patient's Contact Number] — Email Address: [Patient's Email Address] 2. Dates of Treatment: Please provide copies of all medical records covering the period from [Start Date] to [End Date] or include all available records if specific dates are not mentioned. 3. Purpose of Request: [Describe the reason why you need the medical records. For example, "I require these records to provide complete medical history to my new primary care physician and to aid in ongoing treatment."] 4. Authorization: If required, enclosed with this letter is a completed and signed Authorization for Release of Medical Records form, granting permission for the release of my medical records. I kindly request you to process my request promptly, ensuring compliance with all privacy regulations. 5. Method of Delivery: Please inform me of the preferred method to obtain the medical records. I am available to pick them up personally, or if it is more convenient, please provide guidance on any fees associated with copying and mailing the records. Should you require any further information or have any questions pertaining to my request, please do not hesitate to contact me at the phone number or email address provided above. I appreciate your attention to this matter and your assistance in promptly fulfilling my request. Thank you for your time and cooperation. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to request the release of my medical records, as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws. I had previously received medical treatment at your esteemed medical facility, and it is essential for me to obtain a copy of my complete medical records for personal reference and to share with my current healthcare providers. Please find below the necessary details to process my request for patient medical records: 1. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number (optional): [Patient's SSN] — Address at the time of treatment: [Patient's Address during treatment] — Phone Number: [Patient's Contact Number] — Email Address: [Patient's Email Address] 2. Dates of Treatment: Please provide copies of all medical records covering the period from [Start Date] to [End Date] or include all available records if specific dates are not mentioned. 3. Purpose of Request: [Describe the reason why you need the medical records. For example, "I require these records to provide complete medical history to my new primary care physician and to aid in ongoing treatment."] 4. Authorization: If required, enclosed with this letter is a completed and signed Authorization for Release of Medical Records form, granting permission for the release of my medical records. I kindly request you to process my request promptly, ensuring compliance with all privacy regulations. 5. Method of Delivery: Please inform me of the preferred method to obtain the medical records. I am available to pick them up personally, or if it is more convenient, please provide guidance on any fees associated with copying and mailing the records. Should you require any further information or have any questions pertaining to my request, please do not hesitate to contact me at the phone number or email address provided above. I appreciate your attention to this matter and your assistance in promptly fulfilling my request. Thank you for your time and cooperation. Sincerely, [Your Name]