Palm Beach Florida Sample Letter for Request for Medical Records

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

Description

Sample Letter for Request for Medical Records Dear [Medical Provider], I am writing to request copies of my medical records from [date range], as I am moving to Palm Beach, Florida and need to transfer my medical history to a new healthcare provider in the area. It is crucial for me to have these records readily available for future medical consultations, and I appreciate your prompt attention to this matter. Please find below the pertinent information needed for the processing of my medical record request: 1. Personal Information: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Social Security Number: [Your SSN— - Patient ID: [Your Unique Patient ID, if applicable] 2. Contact Information: — Current Address: [Your Current Address] — Phone Number: [Your Phone Number— - Email Address: [Your Email Address] 3. Specific Medical Records: — Dates of Service: [Provide the specific dates or range of dates for which you are requesting medical records] — Type of Records: [Specify if you need complete medical records, specific test results, diagnostic reports, surgical notes, etc.] 4. Authorization: — In accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, I authorize the disclosure of my medical records to the designated individual or healthcare facility mentioned below: Name: [Full Name of the New Healthcare Provider] Address: [Address of the New Healthcare Provider] Phone Number: [Phone Number of the New Healthcare Provider] 5. Preferred Delivery Method: — Please indicate your preferred method for receiving the medical records (select one): — Secure Electronic Transmission (email or online portal) — Certified Mai— - Pick-up in Person (if allowed) I kindly request that you inform me of any fees associated with this medical record transfer process. If applicable, please provide detailed instructions on how to make the payment and any required forms that need to be completed. I understand that you may require some time to process my request, but I would be grateful if you could expedite the process due to the urgent need for these records. If you encounter any difficulties or require further information, please do not hesitate to contact me at the provided phone number or email address. Thank you for your attention to this matter, and I look forward to receiving the requested medical records soon. Sincerely, [Your Full Name] [Your Signature — only if sending a physical letter] [Date]

Dear [Medical Provider], I am writing to request copies of my medical records from [date range], as I am moving to Palm Beach, Florida and need to transfer my medical history to a new healthcare provider in the area. It is crucial for me to have these records readily available for future medical consultations, and I appreciate your prompt attention to this matter. Please find below the pertinent information needed for the processing of my medical record request: 1. Personal Information: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Social Security Number: [Your SSN— - Patient ID: [Your Unique Patient ID, if applicable] 2. Contact Information: — Current Address: [Your Current Address] — Phone Number: [Your Phone Number— - Email Address: [Your Email Address] 3. Specific Medical Records: — Dates of Service: [Provide the specific dates or range of dates for which you are requesting medical records] — Type of Records: [Specify if you need complete medical records, specific test results, diagnostic reports, surgical notes, etc.] 4. Authorization: — In accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, I authorize the disclosure of my medical records to the designated individual or healthcare facility mentioned below: Name: [Full Name of the New Healthcare Provider] Address: [Address of the New Healthcare Provider] Phone Number: [Phone Number of the New Healthcare Provider] 5. Preferred Delivery Method: — Please indicate your preferred method for receiving the medical records (select one): — Secure Electronic Transmission (email or online portal) — Certified Mai— - Pick-up in Person (if allowed) I kindly request that you inform me of any fees associated with this medical record transfer process. If applicable, please provide detailed instructions on how to make the payment and any required forms that need to be completed. I understand that you may require some time to process my request, but I would be grateful if you could expedite the process due to the urgent need for these records. If you encounter any difficulties or require further information, please do not hesitate to contact me at the provided phone number or email address. Thank you for your attention to this matter, and I look forward to receiving the requested medical records soon. Sincerely, [Your Full Name] [Your Signature — only if sending a physical letter] [Date]