Chicago Illinois Sample Letter for Request for Medical Records

• Category: Letters - Nonlegal - Requests
• State: Multi-State
• City: Chicago
• Control #: US-0546LR
• Format: Word; Rich Text

Description

Sample Letter for Request for Medical Records Subject: Request for Medical Records: Chicago, Illinois Dear [Medical Provider], I hope this letter finds you well. I am writing to request a copy of my medical records for personal reference and continuity of care. I am a resident of Chicago, Illinois, and have received medical services at your esteemed institution. Please find below the details necessary for the retrieval of my medical records: Patient Information: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Address: [Your Complete Address— - Contact Number: [Your Phone Number] — Email Address: [Your Email Address— - Medical Insurance Information: [Include insurance provider and policy number, if applicable] Date(s) of Service: Please provide the medical records for the following period: [Specify the start and end dates or mention if you need all available records] Specific Records Requested: Please include any and all relevant medical records, including but not limited to: — Examination note— - Diagnoses - Treatment plans — Medicatiohistoryor— - Laboratory results (blood tests, radiology reports, etc.) — Surgical records (if applicable— - Progress reports — Vaccination histor— - A copy of any referrals made Methods of Delivery: I kindly request that the medical records be provided to me in a secure electronic format, such as PDF or through a secure file transfer method. If electronic delivery is not feasible, I am willing to collect a printed copy at your facility during your designated hours of operation. Please inform me of the preferred method and any associated costs, if applicable. Authorization and Consent: To comply with any necessary privacy regulations, I have enclosed a signed Authorization for Release of Medical Records form. By signing this letter, I acknowledge that I understand the potential risks and responsibilities associated with accessing and maintaining my medical records. HIPAA Guidelines: I kindly request that you adhere to the Health Insurance Portability and Accountability Act (HIPAA) guidelines while processing my medical record request. Preserving the confidentiality and security of my personal health information is of utmost importance. Copies and Charges: Please inform me if there are any costs associated with obtaining copies of my medical records. If there are any fees, kindly provide an itemized invoice. I am willing to pay any necessary charges promptly. Please confirm receipt of this letter and inform me of the estimated timeframe required to fulfill my request. Should you require any additional information or have any questions, you can reach me at the contact details provided above. Thank you for your prompt attention to this matter. Your cooperation in providing my medical records is greatly appreciated. I look forward to receiving the requested information at your earliest convenience. Sincerely, [Your Name] [Your Signature] [Date]

Subject: Request for Medical Records: Chicago, Illinois Dear [Medical Provider], I hope this letter finds you well. I am writing to request a copy of my medical records for personal reference and continuity of care. I am a resident of Chicago, Illinois, and have received medical services at your esteemed institution. Please find below the details necessary for the retrieval of my medical records: Patient Information: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Address: [Your Complete Address— - Contact Number: [Your Phone Number] — Email Address: [Your Email Address— - Medical Insurance Information: [Include insurance provider and policy number, if applicable] Date(s) of Service: Please provide the medical records for the following period: [Specify the start and end dates or mention if you need all available records] Specific Records Requested: Please include any and all relevant medical records, including but not limited to: — Examination note— - Diagnoses - Treatment plans — Medicatiohistoryor— - Laboratory results (blood tests, radiology reports, etc.) — Surgical records (if applicable— - Progress reports — Vaccination histor— - A copy of any referrals made Methods of Delivery: I kindly request that the medical records be provided to me in a secure electronic format, such as PDF or through a secure file transfer method. If electronic delivery is not feasible, I am willing to collect a printed copy at your facility during your designated hours of operation. Please inform me of the preferred method and any associated costs, if applicable. Authorization and Consent: To comply with any necessary privacy regulations, I have enclosed a signed Authorization for Release of Medical Records form. By signing this letter, I acknowledge that I understand the potential risks and responsibilities associated with accessing and maintaining my medical records. HIPAA Guidelines: I kindly request that you adhere to the Health Insurance Portability and Accountability Act (HIPAA) guidelines while processing my medical record request. Preserving the confidentiality and security of my personal health information is of utmost importance. Copies and Charges: Please inform me if there are any costs associated with obtaining copies of my medical records. If there are any fees, kindly provide an itemized invoice. I am willing to pay any necessary charges promptly. Please confirm receipt of this letter and inform me of the estimated timeframe required to fulfill my request. Should you require any additional information or have any questions, you can reach me at the contact details provided above. Thank you for your prompt attention to this matter. Your cooperation in providing my medical records is greatly appreciated. I look forward to receiving the requested information at your earliest convenience. Sincerely, [Your Name] [Your Signature] [Date]