Sample Medical Records Request Letter
Replace the <yellow text> with your own appropriate values:
<Name of health care provider - HMO, doctor, clinic, etc>
Medical Records
<Provider's Address>
<Date>
<Your Name>
<Your Address>
<Your Phone Number>
Dear Sir/Madam:
I would like to obtain a complete copy of my medical records.
Please mail me a copy to the address above.
My insurance number is <if this is
applicable, include your insurance number or other identifying
information>.
Please bill me for any applicable copying fees.
Sincerely,
____________________________________
<Sign Above>