[Name of care provider or facility]
Re: [Your medical identification number or other identifier used]
The purpose of this letter is to request copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations.
I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment.
[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 name printed]