Medical Records Request Letter - Template, Sample Form

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The Medical Records Officer / Data Protection Officer
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Dear Sir/Madam,

RE: REQUEST FOR ACCESS TO PERSONAL MEDICAL RECORDS PURSUANT TO THE NIGERIA DATA PROTECTION ACT 2023 AND THE NATIONAL HEALTH ACT 2014

§1. Introduction

1.1 I, ________, am a patient registered with ________ ("the Facility"). My patient identification/health record number is ________.

1.2 I write to formally request access to, and copies of, my personal medical records held by the Facility. This request is made pursuant to my rights as a data subject under sections 34 and 36 of the Nigeria Data Protection Act 2023, and in furtherance of my rights as a healthcare user under sections 25 to 27 of the National Health Act 2014, and the right to information guaranteed under the Freedom of Information Act 2011 (where applicable).

1.3 The purpose of this request is to obtain a second medical opinion from another healthcare provider and to enable continuity of my care.

§2. Records Requested

2.1 I specifically request copies of the following documents and information:

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2.2 The records requested cover the period from ________ to ________.

2.3 I should be grateful if the records be supplied in the following format: ________ (e.g. certified hard copies and/or electronic copies).

§3. Patient Particulars for Identification

3.1 For the purpose of verifying my identity and locating my records, my particulars are as follows:

Patient Name: ________

Patient Address: ________

Date of Birth: ________

Means of Identification (Type & Number): ________

Patient ID/Health Card Number: ________

3.2 A copy of my means of identification is enclosed herewith to facilitate verification in accordance with the Facility's data protection obligations.

§4. Timeframe for Compliance

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4.2 Where the Facility is unable to comply within the said period, I request to be notified in writing of the reasons for the delay and the expected date of compliance.

§5. Fees

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§6. Confidentiality and Data Protection

6.1 I confirm that I am the data subject in respect of the records requested and that I consent to the processing and disclosure of these records to me in accordance with the law.

6.2 Where any record is to be released to or collected by an authorised representative, the said representative is ________, who is duly authorised by me to receive the records on my behalf.

§7. Contact

7.1 Should you require any further information or clarification regarding this request, please contact me by telephone on ________ or by email at ________.

I thank you for your time and assistance in this matter and look forward to your prompt response.

Yours faithfully,

___________________
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(Patient/Data Subject)

Enclosure(s): Copy of means of identification; ________