Notice
The information provided herein is intended solely as a general guide for requesting personal health records. It does not constitute legal or medical advice and should not replace consultation with qualified healthcare or legal professionals. Regulations governing the disclosure of medical documents vary by jurisdiction, and adjustments may be necessary to ensure compliance with applicable laws. The use of this template is at the user’s discretion and we accept no liability for any errors, omissions, or consequences resulting from its use without professional review.
Please note: This is a sample Medical Records Request Letter template for the United States, provided for illustrative purposes only. Actual content may vary based on specific requirements and laws.
Medical Records Request Letter Sample
Recipient Information:
Health Records Department
Hospital or Clinic Name
Address Line 1
City, State, ZIP
Requestor Information:
Name: John Doe
Address: 123 Main Street, City, State ZIP
Phone: (123) 456-7890
Email: [email protected]
Purpose of Request:
To obtain copies of my medical records for personal review and transfer to my new healthcare provider.
Records Requested:
Complete medical history, including lab reports, imaging, and consultation notes from the past five years.
Authorization and Signature:
I authorize the release of my medical records as specified. Please process this request in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
Signature: _____________________________
Date: ________________________________
City, State, ______________________
John Doe (Requestor)