Request for Copies of Medical Records – Example

Last revised: 10-02-2023

Using this Letter

Be sure to send this letter via certified mail with return receipt requested or through a secure method of delivery to ensure that you have documentation of your request. Additionally, check with your healthcare provider for any specific procedures or forms they may require for medical record requests, as processes can vary among providers.

Here’s a template for a letter to request copies of medical records that is HIPAA compliant. Please note that you should personalize it with your own information and specific details.

[Your Name] [Your Address] [City, State, ZIP Code] [Your Email Address] [Your Phone Number] [Date]

[Medical Provider’s Name] [Medical Provider’s Address] [City, State, ZIP Code]

Dear [Medical Provider’s Name],

I am writing to formally request copies of my medical records, including [specify the type of records you need, e.g., medical history, test results, treatment notes], which are currently in your possession. I am making this request in accordance with my rights under the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws.

Please find the details of my request below:

  • Patient Information:
    • Full Name: [Your Full Name]
    • Date of Birth: [Your Date of Birth]
    • Medical Record Number (if known): [Your Medical Record Number, if available]
    • Dates of Treatment: [Specify the relevant dates or date range]
  • Purpose of Request: [Explain the reason for your request, e.g., for personal records, for a second opinion, for legal purposes, etc.]
  • Method of Delivery: [Specify how you would like to receive the records, e.g., electronic format (if available), paper copies, or both]
  • Authorization: I authorize the release of my medical records, including any protected health information (PHI) contained therein, to me or my authorized representative. I understand that I may be responsible for reasonable fees associated with copying and mailing the records, as allowed by applicable laws.
  • Contact Information for Delivery:
    • Delivery Address: [Your Mailing Address, if different from above]
    • Email Address (if requesting electronic format): [Your Email Address]
    • Phone Number (if required for delivery purposes): [Your Phone Number]

I request that you provide these records within the timeframe specified by HIPAA regulations, typically within 30 days from the date of this request. If for any reason you are unable to fulfill this request within the specified timeframe, please inform me in writing of the reason for the delay and provide an estimated completion date.

If you require any additional information or documentation to process this request, please do not hesitate to contact me at the phone number or email address provided above.

I understand the importance of maintaining the confidentiality of medical records and PHI, and I trust that you will take all necessary precautions to ensure the security of the information during transmission and delivery.

Thank you for your prompt attention to this matter. I look forward to receiving the requested records in due course. If you have any questions or concerns, please do not hesitate to contact me.


[Your Signature]

[Your Full Name]