Fulton Georgia Sample Letter for Request for Medical Records

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

Description

Sample Letter for Request for Medical Records [Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP] Subject: Request for Medical Records Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to request a copy of my medical records from your esteemed healthcare facility in Fulton, Georgia. I am in need of these records for personal reference and to provide comprehensive information to my new healthcare provider. Please find below the necessary details for processing my request: Patient's Full Name: [Your Full Name] Date of Birth: [Your Date of Birth] Social Security Number (optional): [Your SSN] Date of Last Appointment: [Date of Last Appointment] Health Insurance Provider: [Insurance Provider Name] Policy Number: [Insurance Policy Number] I kindly request the following information to be included in the medical records: 1. Full medical history including diagnoses, treatments, and medications prescribed 2. Laboratory test results and imaging reports (X-rays, MRIs, CT scans, etc.) 3. All progress notes, consultation reports, and discharge summaries 4. All surgical and procedure reports 5. Immunization records 6. All relevant correspondence, such as referrals to specialists and other healthcare providers 7. Any other pertinent medical documentation related to my healthcare To facilitate the process, I have enclosed a signed Authorization for Release of Medical Records form, granting permission for the transfer of my medical records to the address mentioned below: [Your Full Name] [Your Address] [City, State, ZIP] I kindly request that you provide the requested medical records at your earliest convenience. If there are any associated fees for the preparation and copying of the records, please inform me in advance. I am willing to cover any reasonable costs involved. Should you require any additional information or have any questions regarding this request, please do not hesitate to contact me via the provided contact details. I kindly ask for your cooperation in ensuring a smooth and prompt process. Thank you for your attention to this matter. I greatly appreciate your assistance. Yours sincerely, [Your Full Name]

[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP] Subject: Request for Medical Records Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to request a copy of my medical records from your esteemed healthcare facility in Fulton, Georgia. I am in need of these records for personal reference and to provide comprehensive information to my new healthcare provider. Please find below the necessary details for processing my request: Patient's Full Name: [Your Full Name] Date of Birth: [Your Date of Birth] Social Security Number (optional): [Your SSN] Date of Last Appointment: [Date of Last Appointment] Health Insurance Provider: [Insurance Provider Name] Policy Number: [Insurance Policy Number] I kindly request the following information to be included in the medical records: 1. Full medical history including diagnoses, treatments, and medications prescribed 2. Laboratory test results and imaging reports (X-rays, MRIs, CT scans, etc.) 3. All progress notes, consultation reports, and discharge summaries 4. All surgical and procedure reports 5. Immunization records 6. All relevant correspondence, such as referrals to specialists and other healthcare providers 7. Any other pertinent medical documentation related to my healthcare To facilitate the process, I have enclosed a signed Authorization for Release of Medical Records form, granting permission for the transfer of my medical records to the address mentioned below: [Your Full Name] [Your Address] [City, State, ZIP] I kindly request that you provide the requested medical records at your earliest convenience. If there are any associated fees for the preparation and copying of the records, please inform me in advance. I am willing to cover any reasonable costs involved. Should you require any additional information or have any questions regarding this request, please do not hesitate to contact me via the provided contact details. I kindly ask for your cooperation in ensuring a smooth and prompt process. Thank you for your attention to this matter. I greatly appreciate your assistance. Yours sincerely, [Your Full Name]