Los Angeles California Sample Letter for Request for Patient Medical Records

• Category: Letters - Nonlegal - Medical
• State: Multi-State
• County: Los Angeles
• 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. Los Angeles California Sample Letter for Request for Patient Medical Records [Your Name] [Your Address] [City, State, ZIP Code] [Phone Number] [Email Address] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP Code] Subject: Request for Release of Patient Medical Records Dear [Healthcare Provider's Name], I hope this letter finds you in good health and high spirits. My name is [Your Name], and I am writing to formally request the release of my medical records from [Healthcare Provider's Name]. As a patient in your esteemed healthcare facility, I believe it is essential for me to have access to my complete medical history, including any past and ongoing treatments, diagnoses, medications, and lab results. I kindly request that you provide me with copies of the following medical records: 1. All medical reports, including but not limited to hospitalizations, surgeries, and emergency room visits. 2. Diagnostic test results, such as X-rays, MRI scans, CT scans, and ultrasounds. 3. Laboratory test results, including blood work, urinalysis, and any other relevant test reports. 4. Medication history, including prescriptions, dosage information, and any adverse reactions. 5. Progress notes, treatment plans, and any other documentation related to my healthcare. To facilitate the process, I have attached a signed and completed authorization form for the release of my medical records. I understand that there may be applicable fees for copying and providing these records, and I am prepared to cover such costs. Please notify me in advance regarding the precise fees involved, if any, and the preferred payment method. Furthermore, I kindly request that the copies of my medical records be provided in a standard electronic format to ensure ease of access and storage. If this is not possible, please inform me of the alternative means through which I can obtain my medical records. Patient information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Address: [Patient's Address— - Contact Number: [Patient's Contact Number] I understand that there may be legal and administrative processes involved in the release of medical records. Therefore, I request that you kindly acknowledge receiving this letter and provide an approximate timeline for the release of my requested medical records. If there are any specific procedures I need to follow or any additional documentation required, please inform me promptly, and I will do my best to comply. Please feel free to contact me at [Phone Number] or [Email Address] if you require any further information or if there are any concerns regarding this request. I greatly appreciate your prompt attention to this matter and your assistance in providing me with the requested medical records. Thank you for your cooperation. Sincerely, [Your Name]

Los Angeles California Sample Letter for Request for Patient Medical Records [Your Name] [Your Address] [City, State, ZIP Code] [Phone Number] [Email Address] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP Code] Subject: Request for Release of Patient Medical Records Dear [Healthcare Provider's Name], I hope this letter finds you in good health and high spirits. My name is [Your Name], and I am writing to formally request the release of my medical records from [Healthcare Provider's Name]. As a patient in your esteemed healthcare facility, I believe it is essential for me to have access to my complete medical history, including any past and ongoing treatments, diagnoses, medications, and lab results. I kindly request that you provide me with copies of the following medical records: 1. All medical reports, including but not limited to hospitalizations, surgeries, and emergency room visits. 2. Diagnostic test results, such as X-rays, MRI scans, CT scans, and ultrasounds. 3. Laboratory test results, including blood work, urinalysis, and any other relevant test reports. 4. Medication history, including prescriptions, dosage information, and any adverse reactions. 5. Progress notes, treatment plans, and any other documentation related to my healthcare. To facilitate the process, I have attached a signed and completed authorization form for the release of my medical records. I understand that there may be applicable fees for copying and providing these records, and I am prepared to cover such costs. Please notify me in advance regarding the precise fees involved, if any, and the preferred payment method. Furthermore, I kindly request that the copies of my medical records be provided in a standard electronic format to ensure ease of access and storage. If this is not possible, please inform me of the alternative means through which I can obtain my medical records. Patient information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Address: [Patient's Address— - Contact Number: [Patient's Contact Number] I understand that there may be legal and administrative processes involved in the release of medical records. Therefore, I request that you kindly acknowledge receiving this letter and provide an approximate timeline for the release of my requested medical records. If there are any specific procedures I need to follow or any additional documentation required, please inform me promptly, and I will do my best to comply. Please feel free to contact me at [Phone Number] or [Email Address] if you require any further information or if there are any concerns regarding this request. I greatly appreciate your prompt attention to this matter and your assistance in providing me with the requested medical records. Thank you for your cooperation. Sincerely, [Your Name]