Sample Letter to Healthcare Provider for Your Records

[Your name]
[Your address]

[Name of care provider or facility]

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

Dear ______,



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

I understand that you may charge a "reasonable" 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.

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


[Your signature]
[Your name printed]