Riverside California Sample Letter for Request for Medical Records

• Category: Letters - Nonlegal - Requests
• State: Multi-State
• County: Riverside
• 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] [Medical Facility Name] [Medical Facility Address] [City, State, ZIP] Subject: Request for Medical Records Dear Sir/Madam, I hope this letter finds you well. I am writing to request a copy of my medical records from [Medical Facility Name]. As a patient, I have the legal right to access and obtain copies of my personal health information under the Health Insurance Portability and Accountability Act (HIPAA). Please find below the necessary details for your reference: 1. Patient Information: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Address: [Your Current Address— - Contact Number: [Your Contact Number] — Email Address: [Your Email Address— - Social Security Number: [Your Social Security Number] 2. Dates of Service: — Please provide the medical records for the period starting from [Start Date] to [End Date]. 3. Types of Medical Records Requested: — I am requesting copies of the following medical records: — Consultation note— - Diagnostic test results — Laboratory report— - Radiology reports (X-rays, MRIs, CT scans, etc.) — Surgical record— - Medication history 4. Purpose of Request: — [Briefly mention the reason for your request, e.g., seeking a second opinion, personal record-keeping, specialist referral, etc.] 5. Authorization: — I understand that there may be charges associated with the request for medical records. Please inform me in advance of any charges, and I will gladly pay the necessary fees. 6. Preferred Delivery Method: — Please let me know the available options for receiving the requested medical records, such as in-person pickup, mail, secure email, or online portal access. I kindly request that you process my request within the legally required time frame, which is usually 30 days from the date of receipt. If it is not possible to fulfill the entire request within the specified timeline, please provide me with a partial release of records as soon as possible. Thank you for your attention to this matter. If you have any questions or require any additional information for processing my request, please do not hesitate to contact me at the provided phone number or email address. I look forward to receiving a prompt response and appreciate your cooperation. Sincerely, [Your Full Name]

[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Medical Facility Name] [Medical Facility Address] [City, State, ZIP] Subject: Request for Medical Records Dear Sir/Madam, I hope this letter finds you well. I am writing to request a copy of my medical records from [Medical Facility Name]. As a patient, I have the legal right to access and obtain copies of my personal health information under the Health Insurance Portability and Accountability Act (HIPAA). Please find below the necessary details for your reference: 1. Patient Information: — Full Name: [Your Full Name— - Date of Birth: [Your Date of Birth] — Address: [Your Current Address— - Contact Number: [Your Contact Number] — Email Address: [Your Email Address— - Social Security Number: [Your Social Security Number] 2. Dates of Service: — Please provide the medical records for the period starting from [Start Date] to [End Date]. 3. Types of Medical Records Requested: — I am requesting copies of the following medical records: — Consultation note— - Diagnostic test results — Laboratory report— - Radiology reports (X-rays, MRIs, CT scans, etc.) — Surgical record— - Medication history 4. Purpose of Request: — [Briefly mention the reason for your request, e.g., seeking a second opinion, personal record-keeping, specialist referral, etc.] 5. Authorization: — I understand that there may be charges associated with the request for medical records. Please inform me in advance of any charges, and I will gladly pay the necessary fees. 6. Preferred Delivery Method: — Please let me know the available options for receiving the requested medical records, such as in-person pickup, mail, secure email, or online portal access. I kindly request that you process my request within the legally required time frame, which is usually 30 days from the date of receipt. If it is not possible to fulfill the entire request within the specified timeline, please provide me with a partial release of records as soon as possible. Thank you for your attention to this matter. If you have any questions or require any additional information for processing my request, please do not hesitate to contact me at the provided phone number or email address. I look forward to receiving a prompt response and appreciate your cooperation. Sincerely, [Your Full Name]