Last Updated: 2013-06-13

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>