Medical Records Request Letter - Template, Sample Form

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Dear ________,

RE: REQUEST FOR MEDICAL RECORDS

I am a current patient at ________, and my patient ID/ health card number is ________, and I am writing to request my medical records from your practice. I am requesting my medical records to obtain a second opinion from another healthcare provider.

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My details are as follows:

Patient Name: ________

Patient Address: ________

Patient Date of Birth: ________

I understand that there may be fees associated with providing these records. Please inform me of any charges in advance and provide details on how to process the payment. Additionally, I would appreciate it if you could let me know the estimated timeframe for processing this request. If you have any questions or require more information about my request, please contact me by phone - ________, or by email - ________.

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Yours faithfully,

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