Maricopa Arizona Sample Letter for Request for Medical Records

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

Description

Sample Letter for Request for Medical Records [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Medical Facility Name] [Medical Facility Address] [City, State, ZIP Code] Subject: Request for Medical Records Dear Sir/Madam, I hope this letter finds you in good health. I am writing to request copies of my medical records from [Medical Facility Name]. As a resident of Maricopa, Arizona, I have been receiving medical care at your esteemed institution and I require these records for personal and healthcare-related reasons. I would appreciate it if you could kindly provide me with the following medical records: 1. Complete medical history, including medical conditions, diagnoses, and treatment details. 2. Any laboratory test results, including blood tests, imaging reports (MRI, X-ray, etc.), and pathology reports. 3. Surgical records, if any. 4. Medication and prescription history, including dosage and duration. 5. Immunization records. 6. Progress notes from previous consultations. 7. All correspondence related to my healthcare, such as letters to and from other medical professionals. I understand that there might be fees associated with copying and retrieving these records. Please let me know the cost involved and the preferred method of payment. Also, kindly inform me of any forms or documentation that I need to complete in order to fulfill this request. To ensure the privacy and confidentiality of my personal information, I request that the medical records be provided in a sealed envelope, securely sent to my address mentioned above. If it is more convenient for you, I am open to picking up the records from the medical facility in person. Please notify me in advance if this is the case. I kindly request you to process my request as soon as possible. In accordance with the Health Insurance Portability and Accountability Act (HIPAA), I understand that you have 30 days from receipt of this request to provide me with the requested medical records. Should there be any unforeseen delays or challenges in fulfilling this request, please inform me promptly with a written explanation. Thank you for your attention to this matter. If you have any further questions or require additional information, please do not hesitate to reach me at [Phone Number] or [Email Address]. Your cooperation and prompt response to this matter are greatly appreciated. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Medical Facility Name] [Medical Facility Address] [City, State, ZIP Code] Subject: Request for Medical Records Dear Sir/Madam, I hope this letter finds you in good health. I am writing to request copies of my medical records from [Medical Facility Name]. As a resident of Maricopa, Arizona, I have been receiving medical care at your esteemed institution and I require these records for personal and healthcare-related reasons. I would appreciate it if you could kindly provide me with the following medical records: 1. Complete medical history, including medical conditions, diagnoses, and treatment details. 2. Any laboratory test results, including blood tests, imaging reports (MRI, X-ray, etc.), and pathology reports. 3. Surgical records, if any. 4. Medication and prescription history, including dosage and duration. 5. Immunization records. 6. Progress notes from previous consultations. 7. All correspondence related to my healthcare, such as letters to and from other medical professionals. I understand that there might be fees associated with copying and retrieving these records. Please let me know the cost involved and the preferred method of payment. Also, kindly inform me of any forms or documentation that I need to complete in order to fulfill this request. To ensure the privacy and confidentiality of my personal information, I request that the medical records be provided in a sealed envelope, securely sent to my address mentioned above. If it is more convenient for you, I am open to picking up the records from the medical facility in person. Please notify me in advance if this is the case. I kindly request you to process my request as soon as possible. In accordance with the Health Insurance Portability and Accountability Act (HIPAA), I understand that you have 30 days from receipt of this request to provide me with the requested medical records. Should there be any unforeseen delays or challenges in fulfilling this request, please inform me promptly with a written explanation. Thank you for your attention to this matter. If you have any further questions or require additional information, please do not hesitate to reach me at [Phone Number] or [Email Address]. Your cooperation and prompt response to this matter are greatly appreciated. Sincerely, [Your Name]