[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP Code] Subject: Request for Patient Medical Records Dear [Healthcare Provider's Name], I hope this letter finds you in good health. I am writing to request copies of my medical records for the purpose of personal reference and continuation of care. As a resident of Miami-Dade, Florida, and a patient of your facility, it is crucial for me to maintain accurate and up-to-date records of my medical history. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number: [Patient's SSN, if applicable] I kindly request the following records associated with my medical history: 1. Consultation Reports: — Detailed notes and findings from all medical consultations and examinations. — Specialist or referral consultations, if any. 2. Laboratory Test Results: — Complete copies of all laboratory tests, including blood work, urinalysis, and any other diagnostic procedures conducted. 3. Imaging and Radiology Reports: — X-rays, CT scans, MRI scans, ultrasounds, or any other imaging reports related to my medical condition. 4. Prescription History: — A comprehensive list of all medications prescribed to me by your facility or any other healthcare provider, including dosage and duration of usage. 5. Surgical Reports: — Detailed reports of any surgeries, procedures, or medical interventions I have undergone with your facility. 6. Progress Notes: — Regular progress notes and updates on my medical condition recorded during my visits to your facility. I understand that there may be applicable fees for providing the requested medical records. Kindly inform me of any costs and the preferred method of payment. If the fees exceed a reasonable amount, I request prior notification to discuss further alternatives. As per the Health Insurance Portability and Accountability Act (HIPAA) guidelines, I authorize the release of these medical records solely for my personal use and for sharing with my new healthcare provider, if necessary. I assure you that the confidentiality and privacy of these records will be upheld. Please let me know the estimated timeframe for the completion of this request. If there are any further forms or documents required to expedite the process, please inform me accordingly. Thank you for your prompt attention to this matter. I greatly appreciate your cooperation in providing me with the requested medical records. Should you have any questions, please feel free to contact me at the provided phone number or email address. Yours sincerely, [Your Name]
Miami-Dade Florida Sample Letter for Request for Patient Medical Records
Category:
State:
Multi-State
County:
Miami-Dade
Control #:
US-0328LR
Format:
Word;
Rich Text
Instant download
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] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP Code] Subject: Request for Patient Medical Records Dear [Healthcare Provider's Name], I hope this letter finds you in good health. I am writing to request copies of my medical records for the purpose of personal reference and continuation of care. As a resident of Miami-Dade, Florida, and a patient of your facility, it is crucial for me to maintain accurate and up-to-date records of my medical history. Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number: [Patient's SSN, if applicable] I kindly request the following records associated with my medical history: 1. Consultation Reports: — Detailed notes and findings from all medical consultations and examinations. — Specialist or referral consultations, if any. 2. Laboratory Test Results: — Complete copies of all laboratory tests, including blood work, urinalysis, and any other diagnostic procedures conducted. 3. Imaging and Radiology Reports: — X-rays, CT scans, MRI scans, ultrasounds, or any other imaging reports related to my medical condition. 4. Prescription History: — A comprehensive list of all medications prescribed to me by your facility or any other healthcare provider, including dosage and duration of usage. 5. Surgical Reports: — Detailed reports of any surgeries, procedures, or medical interventions I have undergone with your facility. 6. Progress Notes: — Regular progress notes and updates on my medical condition recorded during my visits to your facility. I understand that there may be applicable fees for providing the requested medical records. Kindly inform me of any costs and the preferred method of payment. If the fees exceed a reasonable amount, I request prior notification to discuss further alternatives. As per the Health Insurance Portability and Accountability Act (HIPAA) guidelines, I authorize the release of these medical records solely for my personal use and for sharing with my new healthcare provider, if necessary. I assure you that the confidentiality and privacy of these records will be upheld. Please let me know the estimated timeframe for the completion of this request. If there are any further forms or documents required to expedite the process, please inform me accordingly. Thank you for your prompt attention to this matter. I greatly appreciate your cooperation in providing me with the requested medical records. Should you have any questions, please feel free to contact me at the provided phone number or email address. Yours sincerely, [Your Name]
