Medical Record Request

[YOUR COMPANY NAME]
[YOUR COMPANY ADDRESS]

January 15, 2078

OmniTrick
Scottsdale, AZ 85250

Subject: Request for Medical Records

To Whom It May Concern,

I am writing to request copies of medical records for Salvador Green, whose details are as follows:

• Date of Birth: March 12, 2055

• Address: Scottsdale, AZ 85250

Please provide records for the following:

• Type of Records: Annual physical exam reports, lab test results, and vaccination history

• Date Range: January 1, 2070, to December 31, 2077

If there are any fees associated with fulfilling this request, please notify me in advance. I am happy to provide the required authorization or identification to facilitate this process.

I would prefer the records to be sent via email to [YOUR EMAIL] or mailed to:

[YOUR NAME]
[YOUR COMPANY NAME]
[YOUR COMPANY ADDRESS]

Please let me know if additional information is needed. I can be reached at [YOUR EMAIL] or [YOUR COMPANY NUMBER].

Thank you for your prompt attention to this matter.

Sincerely,

[YOUR NAME]
Director of Patient Advocacy
[YOUR COMPANY NAME]

Enclosures:

• Signed Authorization Form

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