Houston Texas Sample Letter for Request for Patient Medical Records

• Category: Letters - Nonlegal - Medical
• State: Multi-State
• City: Houston
• 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 Hospital/Clinic] [Address] [City, State, ZIP Code] Subject: Request for Patient Medical Records Dear Sir/Madam, I hope this letter finds you in good health. I am writing to request a copy of the medical records for [Patient's Name], a former patient at your esteemed facility. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Medical record number (if known): [Patient's MAN, if applicable] Purpose of the Request: I am making this request on behalf of [Patient's Full Name] to gather comprehensive medical information for [his/her] ongoing treatment and to facilitate continuity of care. It is crucial to have access to the complete medical history to ensure accurate diagnoses and treatments. Types of Medical Records Requested: Please provide copies of the following medical records for the specified time period: 1. Consultation notes 2. Progress notes 3. Medication administration records 4. Laboratory test results 5. Radiology reports and images 6. Clinical summaries 7. Operative reports (if applicable) 8. Discharge summaries 9. Immunization records 10. Allergies and adverse reactions 11. Any other relevant medical documents Authorization for Release of Medical Records: To comply with patient confidentiality regulations, I have enclosed a completed and signed "Authorization for Release of Medical Records" form. This form authorizes [Hospital/Clinic Name] to release the patient's medical records to [Your Name] or [Your Organization]. Please let me know if there are any additional forms or documents required to complete this request. Preferred Delivery Method: Kindly inform me of the preferred method for delivering the requested medical records. Options may include: — Mail the records to the address provided above. — Provide access to an online portal where digital copies can be downloaded securely. — Arrange a pickup appointment during regular business hours. Timeframe and Costs: I understand that there may be costs associated with processing the request and producing the copies. Please inform me of any fees applicable and provide an estimate of the total charges. Additionally, I request that the medical records be provided within the legally mandated time period of [state the timeframe according to local regulations]. Contact Information: If there are any questions or concerns regarding this request, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address]. I greatly appreciate your prompt attention to this matter. Thank you for your assistance in providing the medical records for [Patient's Name]. Your cooperation is crucial in ensuring comprehensive and effective healthcare for the patient. Sincerely, [Your Name] [Your Title/Position] [Your Organization (if applicable)]

[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Name of Hospital/Clinic] [Address] [City, State, ZIP Code] Subject: Request for Patient Medical Records Dear Sir/Madam, I hope this letter finds you in good health. I am writing to request a copy of the medical records for [Patient's Name], a former patient at your esteemed facility. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Medical record number (if known): [Patient's MAN, if applicable] Purpose of the Request: I am making this request on behalf of [Patient's Full Name] to gather comprehensive medical information for [his/her] ongoing treatment and to facilitate continuity of care. It is crucial to have access to the complete medical history to ensure accurate diagnoses and treatments. Types of Medical Records Requested: Please provide copies of the following medical records for the specified time period: 1. Consultation notes 2. Progress notes 3. Medication administration records 4. Laboratory test results 5. Radiology reports and images 6. Clinical summaries 7. Operative reports (if applicable) 8. Discharge summaries 9. Immunization records 10. Allergies and adverse reactions 11. Any other relevant medical documents Authorization for Release of Medical Records: To comply with patient confidentiality regulations, I have enclosed a completed and signed "Authorization for Release of Medical Records" form. This form authorizes [Hospital/Clinic Name] to release the patient's medical records to [Your Name] or [Your Organization]. Please let me know if there are any additional forms or documents required to complete this request. Preferred Delivery Method: Kindly inform me of the preferred method for delivering the requested medical records. Options may include: — Mail the records to the address provided above. — Provide access to an online portal where digital copies can be downloaded securely. — Arrange a pickup appointment during regular business hours. Timeframe and Costs: I understand that there may be costs associated with processing the request and producing the copies. Please inform me of any fees applicable and provide an estimate of the total charges. Additionally, I request that the medical records be provided within the legally mandated time period of [state the timeframe according to local regulations]. Contact Information: If there are any questions or concerns regarding this request, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address]. I greatly appreciate your prompt attention to this matter. Thank you for your assistance in providing the medical records for [Patient's Name]. Your cooperation is crucial in ensuring comprehensive and effective healthcare for the patient. Sincerely, [Your Name] [Your Title/Position] [Your Organization (if applicable)]