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Medical Records Request

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Select whether the person asking for medical records is asking on their on behalf of whether they are authorized to ask for the records on behalf of a patient.

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RE: Medical Records Request for ________


Dear ________,


I am a current patient of ________ asking that you provide me with a copy of my medical records from your practice. I am requesting my medical records for reasons related to my health insurance.

I have included a signed Authorization of Medical Records Release form with this letter. If there is a charge associated with releasing these medical records, please submit a billing statement with the records and payment will be remitted promptly upon receipt of the records. If you need any further information from me, you may contact me in the following manner:

________

Thank you for your attention to this matter.



Best,





________





Enclosure

AUTHORIZATION OF MEDICAL RECORDS RELEASE


1. Patient Information.

Name: ________
Address: ________
SSN:_______________________
Date of Birth: ________


2. Authorization for Release.

I, ________, hereby authorize the following individual at the following address:

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________

to release, disclose, and deliver the medical information described below to the following individual:

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________


3. Specific Authorization.

I specifically authorize the release of only the following information:

________

I do not give permission for any other use or redisclosure of this information.



_________________________________
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_________________
Date


4. Redisclosure.

This release does not authorize redisclosure of medical information beyond the limits of this consent. The Recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party without further authorization. The following written statement should accompany certain disclosures:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2 and 45 CFR Parts 160 and 164). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and 45 CFR Parts 160 and 164. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

I specifically understand and agree that the redisclosure requirements set out above will apply to these records.


5. Validity.

I understand that this authorization will automatically expire one year from the date of my signature, and that I may revoke this authorization by sending a written notice to the person or entity authorized to make the disclosure described above. I agree that any release which has been made prior to revocation and which was made in reliance upone this authorization shall not constitute a breach of my rights to confidentiality.


I authorize the release of information as indicated above.



_________________________________
________

_________________
Date

See your document
in progress

________
________

________

________
________


RE: Medical Records Request for ________


Dear ________,


I am a current patient of ________ asking that you provide me with a copy of my medical records from your practice. I am requesting my medical records for reasons related to my health insurance.

I have included a signed Authorization of Medical Records Release form with this letter. If there is a charge associated with releasing these medical records, please submit a billing statement with the records and payment will be remitted promptly upon receipt of the records. If you need any further information from me, you may contact me in the following manner:

________

Thank you for your attention to this matter.



Best,





________





Enclosure

AUTHORIZATION OF MEDICAL RECORDS RELEASE


1. Patient Information.

Name: ________
Address: ________
SSN:_______________________
Date of Birth: ________


2. Authorization for Release.

I, ________, hereby authorize the following individual at the following address:

________
________

to release, disclose, and deliver the medical information described below to the following individual:

________
________


3. Specific Authorization.

I specifically authorize the release of only the following information:

________

I do not give permission for any other use or redisclosure of this information.



_________________________________
________


_________________
Date


4. Redisclosure.

This release does not authorize redisclosure of medical information beyond the limits of this consent. The Recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party without further authorization. The following written statement should accompany certain disclosures:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2 and 45 CFR Parts 160 and 164). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and 45 CFR Parts 160 and 164. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

I specifically understand and agree that the redisclosure requirements set out above will apply to these records.


5. Validity.

I understand that this authorization will automatically expire one year from the date of my signature, and that I may revoke this authorization by sending a written notice to the person or entity authorized to make the disclosure described above. I agree that any release which has been made prior to revocation and which was made in reliance upone this authorization shall not constitute a breach of my rights to confidentiality.


I authorize the release of information as indicated above.



_________________________________
________

_________________
Date