Medical Record Request Letter


Subject: Request for Medical Records
To whom it may concern:

I hope this letter finds you in good health. Kindly accept this letter as my formal request to be given copies of my medical records. I underwent knee replacement surgery at your hospital and it is required for my insurance claim and ongoing medical care to have access to these records.

Find below the details related to my surgery at [mentioning the name of the hospital where the surgery was performed]:

Patient’s Full Name[Patient Name]Date of Birth[DOB]
Medical Record Number (if available)[Medical Record #]Date & Time of Surgery[Date & Time]
Applicant info

I would need the following records:

Operative Notes:All the notes in detail about the surgical procedure performed, including any pre-operative and post-operative information or at-home care.
Medical Reports:All reports, which could include diagnostic tests, laboratory reports, and radiological findings, relate to my knee replacement surgery.
Billing Records:All of my pathology reports are associated with the surgery.
Anesthesia Records:Anesthesia charges, anesthesiologist name, and charges.
Pathology Reports:All of my pathology reports are associated with the surgery.
All Other Relevant Medical Documentation:Any other medical records, documents, and bills related to my surgery, care, and recovery.
Data requirement

I realize there may be a reasonable fee for retrieving and copying these records, and I am willing to pay for the medical. Kindly notify me of any fees and provide instructions on how to make the payment.

Kindly have the records sent to the following address:

[Your Address]
[City, State, Zip Code]

I would request that you send the records within 30 days, as the timely receipt of these records is important for my insurance claim and current medical care.

Should you need any more information or documentation to process this request, please do not hesitate to call me at [Your Phone Number] or email me at [Your Email Address]. Your support in this matter is highly appreciated.

Thank you for your prompt attention to this request. Should you experience any delay in sending my records, kindly inform me of the date I will be receiving them. I look forward to receiving the requested records at your earliest convenience.

[Your Name]

Medical record request letter template


Re: Permission for Release of Medical Records

Dear [Recipient Name],

I hope this letter finds you well. I [patient name], born on [date of birth], [your medical record number], am writing to you today to request the release of my medical records from your hospital, [mention hospital name]. These records are required for my personal use and to share with my current healthcare provider.

In healthcare, it is very important to maintain the confidentiality and privacy of medical records. I understand that. For this reason, I am providing this formal written request along with my consent to release the following medical records:

Surgery Report:This should include all the details of the surgical procedures I went through at your facility, paired with any findings and post-surgery instructions.
Discharge Summary:I would need a copy of the discharge details that present any post-surgery home care, a list of medications, and follow-up dates.
Medical Imaging:I would request copies of any medical imaging reports, such as X-rays, MRIs, or CT scans.
Pathology Reports:Do make available any biopsy or pathology reports, if available.
Requested Record detail

I understand that there may be fees associated with the copying and mailing, but not for the time spent locating or retrieving these records. Please inform me of the total cost and your preferred payment method for paying these charges. Payment will be made promptly upon receiving your invoice.

To be sure the transfer of these records is safe and efficient, you can provide them in an electronic format, such as a password-protected PDF document sent by secure email or on a CD, if convenient for you.

Please be assured that I am granting permission for the release of these records for my personal use and to share with my current healthcare provider. I have faith that [mention hospital name] will handle my medical records according to the laws and regulations regarding patient privacy and confidentiality.

I appreciate your swift attention to my request, and I would request that you acknowledge the receipt of this letter. If you need any additional forms or information, or if you have any questions, do not hesitate to call me at [your phone number] or email me at [your email address].

I look forward to your cooperation in providing access to my medical records, which will facilitate my current healthcare management.


[Your Name]

Medical record request letter template

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