Free Medical Records Request Letter Template
Medical Records Request Letter
[Your Name]
123 Maple Street
Springfield, IL 62704
222 555 7777
[Your Email]
September 17, 2055
Dr. John Smith
Springfield Health Clinic
456 Elm Street
Springfield, IL 62704
Subject: Request for Medical Records
Dear Dr. Smith,
I am writing to request copies of my medical records from your facility. I am [Your Name], and my date of birth is March 14, 2030. I am requesting the following records: all medical records from January 1, 2050, to the present, including any laboratory results, imaging reports, and visit summaries.
Please send the requested records to the following address:
[Your Name]
123 Maple Street
Springfield, IL 62704
Alternatively, you may email the records to me at [Your Email].
If you require any further information or an authorization form, please contact me at 222 555 7777.
Thank you for your prompt attention to this matter.
Sincerely,
[Your Name]
