Sample Letter Requesting Medical Records printable pdf download

Sample Letter Requesting Medical Records

Sample letter requeSting medical recordS

[Your name]

[Your address]

[Your phone number]

[Date]

[Name of care provider or facility]

[Address]

Dear :

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

[fill in dates]. Please include all charts, test results, consultation notes and referrals

regarding my medical care.

I understand I may be charged a reasonable fee for copying the records, but that I will not

be charged for time spent locating the records.

Please mail the requested records to me at the above address. I have enclosed a

self-addressed envelope for your convenience. I understand that I will also be charged

for postage.

I have an appointment scheduled on ________________ with Dr._________________________ .

Thank you for your cooperation. Please let me know if you need any additional information.

Sincerely,

[Your signature]

[Your name printed]

NOTE: Under HIPAA guidelines you can be charged a reasonable fee for copying records. You may also be

charged for postage if you ask that records be mailed to you. HIPAA allows 30 days for a provider to respond

to your request for records, with one 30-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.

5530 Wisconsin Avenue, Suite 700 Chevy Chase, MD 20815 Phone 301.656.5050 Fax 301.656.3168

Sample Letter Requesting Medical Records