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Medical Records Request - Template, Sample Form Online

✓ Valid in United States

Create your Medical Records Request - Template, Sample Form Online for use in United States. Answer a few plain-English questions and the document fills in automatically as you go — then download it in Word and PDF, ready to sign or share.

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Medical Records Request - Template, Sample Form Online
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RE: Medical Records Request for ________


Dear ________,


I am a current patient of ________ asking that you provide me with a copy of my medical records from your practice. I am requesting my medical records for reasons related to my health insurance.

I have included a signed Authorization of Medical Records Release form with this letter. If there is a charge associated with releasing these medical records, please submit a billing statement with the records and payment will be remitted promptly upon receipt of the records. If you need any further information from me, you may contact me in the following manner:

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Thank you for your attention to this matter.



Best,





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Enclosure

AUTHORIZATION OF MEDICAL RECORDS RELEASE


1. Patient Information.

Name: ________
Address: ________
SSN:_______________________
Date of Birth: ________


2. Authorization for Release.

I, ________, hereby authorize the following individual at the following address:

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to release, disclose, and deliver the medical information described below to the following individual:

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3. Specific Authorization.

I specifically authorize the release of only the following information:

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I do not give permission for any other use or redisclosure of this information.



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Date


4. Redisclosure.

This release does not authorize redisclosure of medical information beyond the limits of this consent. The Recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party without further authorization. The following written statement should accompany certain disclosures:

I specifically understand and agree that the redisclosure requirements set out above will apply to these records.


5. Expiration.


I authorize the release of information as indicated above.



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Date

Fields you complete are inserted into the document live. This template is general guidance only — not legal advice.