Free Permission to Access Records Letter Template
Permission to Access Records Letter
October 15, 2050
Virginia Auer
Records Manager
Springfield Medical Center
456 Elm Street
Springfield, IL 62701
Dear Virginia Auer,
I am writing to formally request access to my medical records held by Springfield Medical Center. Under the Health Insurance Portability and Accountability Act (HIPAA), I am entitled to request and obtain copies of these records.
The specific records I am requesting include:
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Complete medical history
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Copies of lab test results from 2045 to 2050
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Notes from my visits to Dr. Emily Brown
For your reference, my details are as follows:
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Full Name: [Your Name]
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Date of Birth: January 15, 1985
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Patient ID: 987654321
Please let me know if there are any forms or fees required for processing this request. I would appreciate a response within 30 days to confirm receipt of this request and to provide the records as requested.
Thank you for your attention to this matter. I look forward to your prompt response.
Sincerely,
[Your Name]
[Your Email]
