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