Skip to main content
Phone: (971) 205-3266
Website: johnsonlaw.com
Email: info@johnsonlaw.com

Medical Records Request Letter

HIPAA-compliant template for requesting medical records

Instructions for Use:

  • Fill in all blanks: Complete all fields marked with underlines before sending
  • Sign and date: Your signature and date are required for HIPAA compliance
  • Be specific: Clearly specify the date range and types of records needed
  • Include ID: Attach a copy of your photo ID with the request
  • Follow up: Providers must respond within 30 days under federal law
  • Keep copies: Maintain copies of all requests for your records
_________________________________
(Your Name)
_________________________________
(Your Address)
_________________________________
(City, State, ZIP Code)
_________________________________
(Your Phone Number)
_________________________________
(Your Email Address)
Date: ___/___/______
_________________________________
(Medical Provider/Facility Name)
_________________________________
(Medical Records Department)
_________________________________
(Address)
_________________________________
(City, State, ZIP Code)
RE: Request for Medical Records - HIPAA Authorization

Dear Medical Records Department:

I am writing to request copies of my medical records in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws. Please provide me with copies of the following medical records:

Patient Information:

Patient Name: _________________________________
Date of Birth: ___/___/______
Social Security Number: ___-__-____
Patient ID/Account Number: _________________________________

Medical Records Requested:

Please provide all medical records for the period from ___/___/______ to ___/___/______, including but not limited to:

☐ Office visit notes
☐ Hospital records
☐ Emergency room records
☐ Consultation reports
☐ Operative reports
☐ Discharge summaries
☐ Progress notes
☐ Laboratory results
☐ Radiology reports and images
☐ Pathology reports
☐ Therapy notes
☐ Medication records
☐ Billing records
☐ Other: ____________________

Specific records related to:

_________________________________________________
_________________________________________________
_________________________________________________

Purpose of Request:

☐ Personal use
☐ Legal proceedings
☐ Insurance claim
☐ Continuing medical care
☐ Other: _________________________________

Preferred Method of Delivery:

☐ Mail to address above
☐ Pick up in person
☐ Secure email to: _________________________________
☐ Fax to: _________________________________

Format Preference:

☐ Paper copies
☐ Electronic copies (CD/DVD)
☐ Electronic files (PDF)

I understand that:

  • You have up to 30 days to respond to this request under federal law
  • You may charge reasonable fees for copying and mailing these records
  • I have the right to receive these records in the format requested if readily producible
  • I may revoke this authorization at any time by written notice

Please contact me at the phone number or email address above if you have any questions about this request or need additional information.

Thank you for your prompt attention to this matter.

_________________________________
Patient Signature
_________________________________
Print Name
_________________________________
Date

HIPAA Authorization

I authorize the release of my medical records as described above. I understand that this authorization will expire one year from the date signed unless I specify a different expiration date here: ___/___/______

_________________________________
Patient Signature for HIPAA Authorization