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October 9, 2026
TO (MEDICAL PROVIDER):
[Provider/Facility Name]
[Street Address]
[City], [State] [ZIP]
RE: PATIENT RECORDS REQUEST
Patient Name: [Patient Name]
Date of Birth: [DOB]
SSN (Last 4): [XXXX]
Patient Address: [Street], [City], [ST] [ZIP]
Dear Records Custodian:
Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable state laws, I, the undersigned patient, hereby request and authorize the release of my protected health information (PHI) and medical records as detailed below.
Please provide records for the treatment period beginning [Start Date] to the present date.
Specifically, I am requesting the following documents:
- Entire Medical Chart (including all physician notes, nursing notes, and consultations)
- Complete, Itemized Billing Records (including all charges, payments, and adjustments)
- All Diagnostic Imaging Reports (X-Rays, MRIs, CT Scans, etc.)
- All Laboratory and Pathology Results
- Emergency Room Records and Triage Notes
- Operative, Surgical, and Procedure Reports
Please provide these records in an electronic format (e.g., PDF) if available, as required by the HITECH Act. If electronic formats are not available, please provide printed copies. I understand that a reasonable, cost-based fee may apply for the production of these records. Please notify me in advance if the cost will exceed $50.00.
I request that this request be processed within 30 days of receipt, as mandated by HIPAA regulations (45 CFR § 164.524). Thank you for your prompt attention to this matter.
Sincerely,
[Patient Name]
Patient / Requester
Date: October 9, 2026