Oakland Michigan Sample Letter for Request for Patient Medical Records

• Category: Letters - Nonlegal - Medical
• State: Multi-State
• County: Oakland
• 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] [Date] [Healthcare Provider/Hospital Name] [Provider/Hospital Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Recipient's Name], I hope this letter finds you well. I am writing to formally request copies of my medical records as a patient of your healthcare facility. I have recently moved to a new healthcare provider, and it is essential for me to have a comprehensive set of records for seamless continuity of care. Furthermore, I was a patient at [Hospital/Clinic Name] located in Oakland, Michigan from [Start Date] to [End Date]. My personal information for identification purposes is as follows: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Address: [Patient's Current Address— - Contact Number: [Patient's Phone Number] — Email: [Patient's Email Address— - Insurance Provider: [Patient's Insurance Provider] — Insurance Policy/ID Number: [Patient's Insurance Policy/ID Number] I kindly request that you provide copies of the following documents from my medical record: 1. Admission and Discharge Summary 2. Consultation Notes 3. Laboratory Test Results 4. Radiology/Imaging Reports 5. Progress Notes 6. Surgical Reports, if applicable 7. Medication History 8. Allergies and Reactions 9. Immunization Records 10. Any other relevant medical documents pertaining to my care I understand that there may be associated fees for the retrieval and duplication of these records. Please inform me of any expected costs and provide payment instructions. If possible, I would prefer to receive the records in an electronic format (PDF), as it is easier for me to store and share with my new healthcare provider. Additionally, if there is a specific form or template that your facility requires to process this request, please provide it along with the records or specify where it can be accessed. I kindly request that you expedite the processing of this request as it is crucial for my ongoing medical care. Should you need any further information or have any questions regarding this request, please do not hesitate to contact me at the provided phone number or email address. Thank you in advance for your prompt attention to this matter. I appreciate your cooperation and look forward to receiving my medical records within the required timeframe. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP] [Date] [Healthcare Provider/Hospital Name] [Provider/Hospital Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Recipient's Name], I hope this letter finds you well. I am writing to formally request copies of my medical records as a patient of your healthcare facility. I have recently moved to a new healthcare provider, and it is essential for me to have a comprehensive set of records for seamless continuity of care. Furthermore, I was a patient at [Hospital/Clinic Name] located in Oakland, Michigan from [Start Date] to [End Date]. My personal information for identification purposes is as follows: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Address: [Patient's Current Address— - Contact Number: [Patient's Phone Number] — Email: [Patient's Email Address— - Insurance Provider: [Patient's Insurance Provider] — Insurance Policy/ID Number: [Patient's Insurance Policy/ID Number] I kindly request that you provide copies of the following documents from my medical record: 1. Admission and Discharge Summary 2. Consultation Notes 3. Laboratory Test Results 4. Radiology/Imaging Reports 5. Progress Notes 6. Surgical Reports, if applicable 7. Medication History 8. Allergies and Reactions 9. Immunization Records 10. Any other relevant medical documents pertaining to my care I understand that there may be associated fees for the retrieval and duplication of these records. Please inform me of any expected costs and provide payment instructions. If possible, I would prefer to receive the records in an electronic format (PDF), as it is easier for me to store and share with my new healthcare provider. Additionally, if there is a specific form or template that your facility requires to process this request, please provide it along with the records or specify where it can be accessed. I kindly request that you expedite the processing of this request as it is crucial for my ongoing medical care. Should you need any further information or have any questions regarding this request, please do not hesitate to contact me at the provided phone number or email address. Thank you in advance for your prompt attention to this matter. I appreciate your cooperation and look forward to receiving my medical records within the required timeframe. Sincerely, [Your Name]