Fairfax Virginia Sample Letter for Request for Medical Records

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

Description

Sample Letter for Request for Medical Records Subject: Request for Medical Records — Fairfax, Virginia Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to request copies of my medical records for the purpose of personal reference and continuity of care. I have been receiving medical treatment at your facility, [Facility Name], in Fairfax, Virginia, and I would greatly appreciate your assistance in providing me with the necessary documentation. Kindly allow me to provide some relevant details for easier identification of my records: 1. Patient Information: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Address: [Your Full Address— - Contact Number: [Your Phone Number] 2. Dates of Treatment: — Start Date: [Start Date of Treatment— - End Date (if applicable): [End Date of Treatment] 3. Physician(s) Information: — Primary Care Physician: [Physician's Name] — Specialist(s) (if any): [Specialist Names] I request the following medical records: 1. General Medical Records: — Comprehensive medicahistoryor— - Lab test results — Diagnostic reports (e.g., X-rays, MRI, CT scans) — Progress note— - Surgical records (if any) — Immunization record— - Medication and prescription history — Allergies and adverse reaction— - Treatment plans 2. Specific Documents (if applicable): — Emergency room visit report— - Hospital admission and discharge summaries — Consultation notes from specialist— - Rehabilitation or physical therapy records Please inform me of any fees associated with the retrieval of these records, including copying and postage fees. I am prepared to reimburse any reasonable expenses promptly. Additionally, if it would facilitate the process, I am more than willing to schedule an appointment to come in person and collect the copies at your convenience. To comply with applicable laws and regulations, I kindly request that you provide the requested records within the timeframe stipulated by law or any internal procedures your facility follows. In case you require any further clarification or have any questions, kindly reach me at the contact information provided above. Thank you for your prompt attention to this matter, and I greatly appreciate your cooperation. Sincerely, [Your Full Name] [Your Signature] [Date]

Subject: Request for Medical Records — Fairfax, Virginia Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to request copies of my medical records for the purpose of personal reference and continuity of care. I have been receiving medical treatment at your facility, [Facility Name], in Fairfax, Virginia, and I would greatly appreciate your assistance in providing me with the necessary documentation. Kindly allow me to provide some relevant details for easier identification of my records: 1. Patient Information: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Address: [Your Full Address— - Contact Number: [Your Phone Number] 2. Dates of Treatment: — Start Date: [Start Date of Treatment— - End Date (if applicable): [End Date of Treatment] 3. Physician(s) Information: — Primary Care Physician: [Physician's Name] — Specialist(s) (if any): [Specialist Names] I request the following medical records: 1. General Medical Records: — Comprehensive medicahistoryor— - Lab test results — Diagnostic reports (e.g., X-rays, MRI, CT scans) — Progress note— - Surgical records (if any) — Immunization record— - Medication and prescription history — Allergies and adverse reaction— - Treatment plans 2. Specific Documents (if applicable): — Emergency room visit report— - Hospital admission and discharge summaries — Consultation notes from specialist— - Rehabilitation or physical therapy records Please inform me of any fees associated with the retrieval of these records, including copying and postage fees. I am prepared to reimburse any reasonable expenses promptly. Additionally, if it would facilitate the process, I am more than willing to schedule an appointment to come in person and collect the copies at your convenience. To comply with applicable laws and regulations, I kindly request that you provide the requested records within the timeframe stipulated by law or any internal procedures your facility follows. In case you require any further clarification or have any questions, kindly reach me at the contact information provided above. Thank you for your prompt attention to this matter, and I greatly appreciate your cooperation. Sincerely, [Your Full Name] [Your Signature] [Date]