First Request Of Medical Records printable pdf download

First Request Of Medical Records

*****FIRST REQUEST – delete this when preparing your own letter*****

Your Name

Your Street Address

Your City, State ZIP

Your Phone Number

Your Email Address

Date

Doctor's Name

Doctor's Street Address

Doctor's City, State ZIP

Dear Dr. _________,

As per California Health & Safety Code Sections 123100-123149, I am requesting a

copy of my medical records, including chart notes; pharmacy and durable medical

equipment prescription records; laboratory test results; radiology, ultrasound and

surgical reports; referral records; and any letters and reports from and to consulting

or referring physicians.

I understand that your office is entitled to charge me reasonable costs for the copying

of my records. I will be happy to come in an assist with the photocopying, if that will

help your office get my file copied and to me within the 15 days stipulated in the

Code. I will also be happy to pick up the copies from your office upon notification that

they are ready to be picked up.

If you have any questions, please feel free to contact me.

Your Signature

Your Name

First Request Of Medical Records