[Name of care provider or facility]
RE: [Your medical identification number or other identifier used]
The purpose of this letter is to request copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and the Department of Health and Human Services regulations.
I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment.
[Identify records requested, e.g. medical history form you provided; physician and nurses’ notes; test results, consultations with specialists; referrals.]
[Note: HIPAA also allows you to request a summary of your medical records. If you prefer a summary, you should agree to a fee beforehand.]
I understand you may charge a reasonable fee for copying the records, but will not charge for time spent locating the records. Please mail the requested records to me
I look forward to receiving the above records within 30 days as specified under HIPAA. If my request cannot be honored within 30 days, please inform me of this by letter as well as the date I might expect to receive my records*.
[Your name printed]
*Under HIPAA you can be charged a reasonable fee for copying records. You may also be charged for the postage if you ask that records be