Phoenix Arizona Sample Letter for Request for Patient Medical Records

• Category: Letters - Nonlegal - Medical
• State: Multi-State
• City: Phoenix
• 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] [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 and high spirits. I am writing to formally request a copy of my medical records from the [Patient Name] department at [Healthcare Provider's Name]. I believe having access to these records is crucial for better understanding my medical history and facilitating any necessary future healthcare decisions. To assist you in locating the appropriate patient files, please find the requested details below: Patient Information: — Patient Name: [Full Name— - Date of Birth: [Date of Birth] — Social Security Number: [SSN], if available — Address: [Current Address] Medical Record Details: — Dates of Service: [Start Date] to [End Date] or "all available records" — Specific Departments or Physicians: [Name(s) of Departments or Physicians, if applicable] To ensure the request is processed efficiently, I kindly request that you provide the records in a timely manner, preferably within 30 days from the date of this letter, as mandated by the HIPAA Privacy Rule. Should additional time be required to gather the necessary files, please inform me promptly, outlining the reasons for the delay and the expected timeline for delivery. In terms of delivery, I would prefer to receive the records in an electronic format, specifically in PDF or JPEG files, securely shared via email ([Email Address] provided above). However, if a different method is preferred or required, kindly let me know. Please note that I understand certain charges may apply for the retrieval and duplication of my medical records as permitted within state and federal laws. If any fees are applicable, please inform me of the cost in advance, and I will promptly make the necessary payment. Lastly, I want to express my appreciation for your prompt attention to this matter and for your dedication to maintaining accurate medical records. Should you have any questions or require additional information to fulfill my request, please do not hesitate to contact me. I can be reached at the provided phone number or via email. Thank you for your anticipated cooperation and assistance. I look forward to receiving my medical records to ensure I have a comprehensive understanding of my healthcare history. Yours sincerely, [Your Name]

[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 and high spirits. I am writing to formally request a copy of my medical records from the [Patient Name] department at [Healthcare Provider's Name]. I believe having access to these records is crucial for better understanding my medical history and facilitating any necessary future healthcare decisions. To assist you in locating the appropriate patient files, please find the requested details below: Patient Information: — Patient Name: [Full Name— - Date of Birth: [Date of Birth] — Social Security Number: [SSN], if available — Address: [Current Address] Medical Record Details: — Dates of Service: [Start Date] to [End Date] or "all available records" — Specific Departments or Physicians: [Name(s) of Departments or Physicians, if applicable] To ensure the request is processed efficiently, I kindly request that you provide the records in a timely manner, preferably within 30 days from the date of this letter, as mandated by the HIPAA Privacy Rule. Should additional time be required to gather the necessary files, please inform me promptly, outlining the reasons for the delay and the expected timeline for delivery. In terms of delivery, I would prefer to receive the records in an electronic format, specifically in PDF or JPEG files, securely shared via email ([Email Address] provided above). However, if a different method is preferred or required, kindly let me know. Please note that I understand certain charges may apply for the retrieval and duplication of my medical records as permitted within state and federal laws. If any fees are applicable, please inform me of the cost in advance, and I will promptly make the necessary payment. Lastly, I want to express my appreciation for your prompt attention to this matter and for your dedication to maintaining accurate medical records. Should you have any questions or require additional information to fulfill my request, please do not hesitate to contact me. I can be reached at the provided phone number or via email. Thank you for your anticipated cooperation and assistance. I look forward to receiving my medical records to ensure I have a comprehensive understanding of my healthcare history. Yours sincerely, [Your Name]