Medical Release Letter (Free Sample)
Use this sample medical release letter as a template for your formal release letter.
Last updated on August 19th, 2022
Medical Release Letter Sample
Date
Your Name
Your Address
City, State, Zip Code
Doctor or Hospital’s Name
Address
City, State, Zip Code
RE: Medical identification number and Date of Birth
Dear Doctor’s Name or Hospital Records Department,
I am writing this letter to request copies of my medical records that are in Name of Hospital or Doctor’s Office. I understand that the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations allow me to have these copies.
I received treatment in your facilities from Date, Year to Date, Year. I would like to have copies of all my records that relate to this treatment. This may include the medical history I previously provided to you, consultations with specialists and test results.
I will be happy to pay a fee for copying the records and for postage to send them to the above address.
According to the HIPAA, I can expect to receive my medical records within 30 days. It this is not possible, kindly inform me in writing and tell me when to expect the records.
If you have any questions or require more information, call me at 555 123 4567 or email me at [email protected].
Thank you for your time.
Sincerely,
Your Signature
Your Name in print
Medical release form enclosed
By Andre Bradley
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