| Date of letter |
|
| Your name Your mailing address Your phone number |
|
| Name of medical provider Mailing address of medical provider |
|
| ATTN: |
Medical Records Department |
| RE: |
Your full name Your date of birth Your Social Security number Your patient ID number (if applicable) Dates of your treatment |
|
Dear Sir/Madam: Please accept this letter as my formal written request for the release to me of copies of my complete medical records. I make this request pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Department of Health and Human Services regulations. The regulations contained therein designate the process of requesting medical records. My intention is to fully comply with those regulations. The medical records I am requesting represent the dates of my treatment beginning on (date you started treatment) and ending on (date you ended treatment). They should include, but not be limited to: I understand there may be a reasonable fee required for the assembly, copying, and mailing of these records. If you tell me the cost I will be happy to pay it either now or when you complete the process. Please mail these records to me at the address listed above. I understand and appreciate you may need some time to assemble this information. I am confident you will have the records ready within the 30-day period allowed by HIPAA. If you have any questions, or if any of the above is unclear, please do not hesitate to contact me. Yours truly, (Your name/signature) |
|
