[Your name]
[Your address]
[Date]

[Name of care provider or facility]
[Address]

RE: [Your medical identification number or other identifier used]

Dear

The purpose of this letter is to request copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations.

I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment.

[Identify records requested, e.g. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals.]

[Note: HIPAA also allows you to request a summary of your medical records. If you prefer a summary, you should agree to a fee beforehand.]

I understand you may charge a ìreasonableî fee for copying the records, but will not charge for time spent locating the records. Please mail the requested records to me at the above address. [If you request that the records be mailed, you may also be charged for postage.]*

I look forward to receiving the above records within 30 days as specified under HIPAA. If my request cannot be honored within 30 days, please inform me of this by letter as well as the date I might expect to receive my records*.

Sincerely,

 

[Your signature]
[Your name printed]

*Under HIPAA you can be charged a ìreasonableî fee for copying records. You may also be charged for postage if you ask that records be mailed to you. HIPAA allows 30 days for a provider to respond to your request for records, with one 30-day extension for good reason.

Your state laws may include a lower fee for copies of records or a shorter time for the provider to respond to your request. The Georgetown University Center on Medical Rights and Privacy includes state-specific guides for 32 states. Before composing your request for medical records, visit this site for information about your state. http://hpi.georgetown.edu/privacy/records.html

 

 


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