Fill in the details
0/100 of 10 completed
Type below - the document on the right updates as you go.
The clauses below are blurred in the preview. Fill in your details, then pay once to unlock the full document and download it as Word & PDF.
Proceed to payment →🔒 Secure & private · ⚡ Instant download after payment · One-time payment · no subscription
________
________
________
________
________
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:
________
Thank you for your attention to this matter.
Best,
________
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:
________
________
to release, disclose, and deliver the medical information described below to the following individual:
________
________
3. Specific Authorization.
I specifically authorize the release of only the following information:
________
I do not give permission for any other use or redisclosure of this information.
_________________________________
________
_________________
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.
_________________________________
________
_________________
Date
Fields you complete are inserted into the document live. This template is general guidance only - not legal advice.