Sample Medical Records Search Letter printable pdf download

Sample Medical Records Search Letter

Sample Letter

Date

Name of Doctor, Hospital or Records Custodian

Address

City and State

Re: Patient name: (your mother's name, including her maiden name)

Date of Birth: (her date of birth)

Soc. Sec. No.: (her social security number)

Date of Treatment: (dates of her pregnancy treatment for doctor's

records or dates of hospital stays for hospital or labor and

delivery records)

Dear <name> :

I am the (daughter/son) of (Mother's name), a former patient of yours.

Please provide the undersigned with a complete copy of (Mother's name)'s

entire file, including all physician and nursing notes, operative reports,

orders, lab results, x-ray reports, correspondence and insurance

information. I would appreciate receiving these records as soon as

possible, and I enclose a signed authorization allowing their release. Any

reasonable copy charges (less than $35) will be promptly paid; however,

should the costs exceed that amount, I would appreciate a call first at

(Your Phone Number). If you have any questions or require any additional

information, please feel free to contact me.

Sincerely,

Your Name and Address

Sample Medical Records Search Letter