Pima Arizona Sample Letter for Request for Patient Medical Records

• Category: Letters - Nonlegal - Medical
• State: Multi-State
• County: Pima
• 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. Sample Letter for Request for Patient Medical Records in Lima, Arizona Dear [Healthcare Provider's Name], I am writing to request a copy of my medical records as a patient of your healthcare facility in Lima, Arizona. As per my rights under the Health Insurance Portability and Accountability Act (HIPAA) and applicable state and federal laws, I have the right to access these records. I appreciate your cooperation in providing these records in a timely and efficient manner. Patient Information: — Patient Name: [Full Name— - Date of Birth: [DOB] — Social Security Number (if available): [SSN] — Address: [Current Address— - Phone Number: [Contact Number] Medical Record Details: 1. Diagnostic Information: I request copies of any medical tests, diagnostic reports, and imaging studies (such as X-rays, MRIs, and CT scans) conducted during my treatment at your facility. This includes reports of blood tests, biopsies, pathology reports, and any other relevant diagnostic evaluations. 2. Treatment History: Please provide a comprehensive record of the treatments I have received, including medication prescriptions, dosage information, and details of surgical procedures or medical interventions performed. 3. Progress Notes: Requesting copies of progress notes, consultation reports, and physician's notes recorded during my visits would greatly assist in obtaining a complete picture of my medical history. Additional Information: — Requested Date Range: Please include all medical records from [Starting Date] to [Ending Date]. — Authorization: I understand that there may be a fee associated with copying and processing the requested medical records. Please inform me of any charges and provide me with the necessary payment instructions. I authorize the release of my medical records to myself and/or my designated representative. — Delivery Method: Kindly let me know the available options for receiving the requested medical records (mail, fax, secure email, etc.) and any relevant instructions to facilitate the process. If you require any further information or documentation to process my request, please let me know. I kindly request that you acknowledge receipt of this letter within 10 business days. Thank you for your attention to this matter. I am eager to receive my medical records promptly to better manage my healthcare needs. Your cooperation and assistance are greatly appreciated. Sincerely, [Your Full Name] [Your Contact Information]

Sample Letter for Request for Patient Medical Records in Lima, Arizona Dear [Healthcare Provider's Name], I am writing to request a copy of my medical records as a patient of your healthcare facility in Lima, Arizona. As per my rights under the Health Insurance Portability and Accountability Act (HIPAA) and applicable state and federal laws, I have the right to access these records. I appreciate your cooperation in providing these records in a timely and efficient manner. Patient Information: — Patient Name: [Full Name— - Date of Birth: [DOB] — Social Security Number (if available): [SSN] — Address: [Current Address— - Phone Number: [Contact Number] Medical Record Details: 1. Diagnostic Information: I request copies of any medical tests, diagnostic reports, and imaging studies (such as X-rays, MRIs, and CT scans) conducted during my treatment at your facility. This includes reports of blood tests, biopsies, pathology reports, and any other relevant diagnostic evaluations. 2. Treatment History: Please provide a comprehensive record of the treatments I have received, including medication prescriptions, dosage information, and details of surgical procedures or medical interventions performed. 3. Progress Notes: Requesting copies of progress notes, consultation reports, and physician's notes recorded during my visits would greatly assist in obtaining a complete picture of my medical history. Additional Information: — Requested Date Range: Please include all medical records from [Starting Date] to [Ending Date]. — Authorization: I understand that there may be a fee associated with copying and processing the requested medical records. Please inform me of any charges and provide me with the necessary payment instructions. I authorize the release of my medical records to myself and/or my designated representative. — Delivery Method: Kindly let me know the available options for receiving the requested medical records (mail, fax, secure email, etc.) and any relevant instructions to facilitate the process. If you require any further information or documentation to process my request, please let me know. I kindly request that you acknowledge receipt of this letter within 10 business days. Thank you for your attention to this matter. I am eager to receive my medical records promptly to better manage my healthcare needs. Your cooperation and assistance are greatly appreciated. Sincerely, [Your Full Name] [Your Contact Information]