However, you will not charge for time spent locating the records. I understand you may charge a reasonable fee for copying the records, as well as for postage to mail the reports to the above address. I would like copies of all of my blood test results, imaging studies, operative reports, as well as notes from doctors and nurses, consultations with specialists, referrals and any other record in my medical file. I was treated in your FACILITY from DATE to DATE. I have understood that according to the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations, I am entitled to have copies of my medical records. ID number: NUMBER Dear Name of Healthcare Provider, I am writing this letter to request copies of any medical records of mine that you have. Sample Medical Records Request Letter Individual’s Name Individual’s Address City, State, Zip Code DATE Name of Healthcare provider Name of Hospital or other Facility if applicable Address of Healthcare provider City, State, Zip Code RE: Requesting copies of my medical records. Since there is a time frame for the healthcare provider to answer, it is wise for the individual to have proof of the time the letter was received. It should be written in formal business style and sent by certified mail. Here is a sample medical records request letter. Each hospital may have different regulations for handling next-of-kin applications, so the person should call the hospital to find out their regulations. If they would like to request the medical records of a deceased person, they will need the permission of the next of kin. If they want to request a family member’s records, they will need written permission from the family member. However, an individual can only request their own medical records. The records can be sent to the individual’s residence, another doctor’s office or to an insurance company. The form can be filled out, signed and included in the letter requesting the records. The individual should call the office and ask if this is required because it will save time for the person looking for the records, thereby saving time for the individual requesting. Thank you for your anticipated cooperation in this matter.Medical Release Form Many doctors and hospitals require that patients fill out a medical release form. I look forward to (insert name of insurance company)’s response by (insert a date that’s a week from the date of the letter). As you can imagine, this matter is extremely important to us. Thank you in advance for your prompt and complete reply. Please (email, call or mail) us with:ġ) The exact wording of the policy language you are relying on to reject our claim.Ģ) Complete copies of all evaluations, reports, estimates you have prepared or caused to be prepared that relate to our property and the claim referenced in this letter. (Optional: As you know, we have suffered a major loss that is having a big impact on our lives and we are struggling to recover). The purpose of this letter is to request that you keep us informed on our claim by giving us the following information at your earliest convenience, and no later than one week from today. RE: Request for information about claim denialĭear (insert name of Insurance Adjuster/Insurance Company Representative), (Name of adjuster or highest ranking ins. Use this letter to request information about your claim denial. All bracketed and underlined portions must be completed or revised before sending. NOTE: This letter is a sample that must be customized to fit the facts of your individual situation and claim.
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