Cuyahoga Ohio Sample Letter for Request for Patient Medical Records

• Category: Letters - Nonlegal - Medical
• State: Multi-State
• County: Cuyahoga
• 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] [Email Address] [Phone Number] [Date] [Name of Healthcare Facility] [Address of Healthcare Facility] [City, State, Zip Code] Subject: Request for Patient Medical Records Dear [Healthcare Facility's Name], I hope this letter finds you well. I am writing to formally request the release of the medical records of [Patient's Full Name], in accordance with state and federal laws regarding patient privacy and the Health Insurance Portability and Accountability Act (HIPAA). Please find below the necessary details related to the patient: Patient's Full Name: Date of Birth: Address: Phone Number: Social Security Number (last four digits only): Date(s) of Service: I kindly request that you provide copies of the complete medical records for the above-mentioned patient, including but not limited to: 1. Consultation notes and progress summaries 2. Laboratory test results 3. Imaging or diagnostic reports (X-rays, MRI, CT scans, etc.) 4. Surgical reports and operative notes 5. Prescription and medication history 6. Immunization records 7. Rehabilitation or physical therapy records 8. Correspondence with other healthcare providers 9. Mental health or counseling records, if applicable I understand that there may be a fee associated with this request, as stated by Ohio law. Please provide me with information concerning the estimated costs and the preferred method of payment. If the cost exceeds $50, kindly notify me before proceeding. Additionally, as per HIPAA guidelines, I would be grateful if you could provide the medical records in an electronic format, such as a secure email attachment or a password-protected CD. This will help ensure the confidentiality and security of the records. I would like to receive the requested medical records within 30 days of the receipt of this letter. If, for any reason, this timeline cannot be met, please inform me in writing with an explanation of the delay. I appreciate your prompt attention to this matter and your cooperation in fulfilling my request. If you have any questions or require further information, please do not hesitate to contact me at the provided phone number or email address. Thank you for your time and assistance, and I look forward to receiving the medical records at your earliest convenience. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, Zip Code] [Email Address] [Phone Number] [Date] [Name of Healthcare Facility] [Address of Healthcare Facility] [City, State, Zip Code] Subject: Request for Patient Medical Records Dear [Healthcare Facility's Name], I hope this letter finds you well. I am writing to formally request the release of the medical records of [Patient's Full Name], in accordance with state and federal laws regarding patient privacy and the Health Insurance Portability and Accountability Act (HIPAA). Please find below the necessary details related to the patient: Patient's Full Name: Date of Birth: Address: Phone Number: Social Security Number (last four digits only): Date(s) of Service: I kindly request that you provide copies of the complete medical records for the above-mentioned patient, including but not limited to: 1. Consultation notes and progress summaries 2. Laboratory test results 3. Imaging or diagnostic reports (X-rays, MRI, CT scans, etc.) 4. Surgical reports and operative notes 5. Prescription and medication history 6. Immunization records 7. Rehabilitation or physical therapy records 8. Correspondence with other healthcare providers 9. Mental health or counseling records, if applicable I understand that there may be a fee associated with this request, as stated by Ohio law. Please provide me with information concerning the estimated costs and the preferred method of payment. If the cost exceeds $50, kindly notify me before proceeding. Additionally, as per HIPAA guidelines, I would be grateful if you could provide the medical records in an electronic format, such as a secure email attachment or a password-protected CD. This will help ensure the confidentiality and security of the records. I would like to receive the requested medical records within 30 days of the receipt of this letter. If, for any reason, this timeline cannot be met, please inform me in writing with an explanation of the delay. I appreciate your prompt attention to this matter and your cooperation in fulfilling my request. If you have any questions or require further information, please do not hesitate to contact me at the provided phone number or email address. Thank you for your time and assistance, and I look forward to receiving the medical records at your earliest convenience. Sincerely, [Your Name]