Letter Of Agreement printable pdf download

Letter Of Agreement

Letter of Agreement

[Your Name]

[Address]

[City, State, Zip]

[Date of letter]

[Name of Care Provider or Facility]

[Address]

[City, State, Zip]

Dear [Recipient’s name],

I am writing you to request copies of my medical records. I was treated in your office on

[xx/xx/xxxx]. Please include all of my charts, test results, and consultation notes including

referrals regarding my medical care.

I understand I may be charged a fee that is reasonable for the copying of my medical records,

however, I will not be charged for any time that is spent locating my records.

Please mail the requested information to me at the address listed above. I have enclosed a self-

addressed envelope for your convenience. I understand that I will be charged for postage.

Best regards,

[Your signature]

[Your name printed]

Note: Under HIPAA guidelines you may be charged for a reasonable fee for copying records.

You may also be charged for postage if you request that records be mailed to you. HIPAA allows

thirty days for a provider to respond to your request for records, with one thirty day extension

for good reason. Your specific state laws may include a lower fee for copies of records or a

shorter time for the provider to respond to your request.

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Letter Of Agreement