[Your Name] [Your Address] [City, State, Zip] [Email Address] [Phone Number] [Date] [Name of Medical Facility] [Address] [City, State, Zip] Subject: Request for Medical Records Dear [Medical Facility's Name], I hope this letter finds you in good health. I am writing to formally request copies of my medical records as allowed by law under the District of Columbia's regulations. I am a resident of the District of Columbia and a patient of your esteemed medical facility. As I believe it is essential to maintain a complete personal medical history, I kindly request that you provide me with copies of my medical records for the following time period: [start date] to [end date]. To facilitate this process, I would appreciate it if you could include all the following relevant information in the medical records: 1. Consultations and examinations conducted by any medical practitioners within the facility 2. Laboratory test results 3. Radiology and diagnostic imaging reports 4. Surgical procedures performed, including associated operative reports 5. Prescriptions or medication history 6. Any documentation related to hospital admissions, discharges, or overnight stays 7. Immunization records 8. Psychological or psychiatric evaluations (if applicable) To ensure accurate identification and prompt processing of my request, I have attached a copy of my government-issued identification document (e.g., driver's license, passport) and any additional documentation required by your facility. Please inform me if there are any further forms or fees necessary to fulfill this request. I kindly request that you provide these records within the legally prescribed timeframe of up to 30 days. If for any reason my request cannot be honored within this period, please inform me promptly with an explanation and an estimate of when the records will be available. In accordance with District of Columbia regulations, I understand that reasonable fees may be applied for the duplication and preparation of these records. However, I kindly request that you provide me with an itemized list detailing the costs associated with this request in advance. Please note that I will be responsible for any applicable fees and charges associated with this request. If you have any inquiries or require additional information, please do not hesitate to contact me at the provided email address or phone number. Your cooperation and prompt attention to this matter are greatly appreciated. Thank you for your assistance. I look forward to receiving my medical records in a timely manner. Sincerely, [Your Name]
District of Columbia Sample Letter for Request for Medical Records
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How to fill out Sample Letter For Request For Medical Records?
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FAQ
How to Request Your Medical Records. Most practices or facilities will ask you to fill out a form to request your medical records. This request form can usually be collected at the office or delivered by fax, postal service, or email. If the office doesn't have a form, you can write a letter to make your request.
If the patient wrote a personal letter requesting records, make sure the following patient information was in the original request:Date of birth.Name.Social Security number.Contact information (address and phone number)Email address.Dates of service and specific records requested (tests, discharge notes, etc.)More items...
(c) Medical or client records shall be maintained for a minimum period of 3 years from the date of last contact for an adult and a minimum period of 3 years after a minor reaches the age of majority.
The subject line of your request should be "FOIL Request". Please inform me of the cost of providing paper copies of the following records include as much detail about the records as possible, including relevant dates, names, descriptions, etc..
If the patient wrote a personal letter requesting records, make sure the following patient information was in the original request:Date of birth.Name.Social Security number.Contact information (address and phone number)Email address.Dates of service and specific records requested (tests, discharge notes, etc.)More items...
To request a record, you must submit a completed Request for Release of Information / Authorization HIPAA Form 3 DBH Privacy Officer. You can submit the request by mail or fax. The Medical Records hours of operation are Monday- Friday am pm (when the District government is open).
What information should be included in a patient's medical records?The initial health history and physical examination from the doctor.Consultation reports from specialists, as well as any notes.Operative reports / Medical procedure reports.More items...?
Before you write a request letter, one should know to whom the letter is addressed....Here is the simple format of the request letter:Date.Recipient Name, designation and address.Subject.Salutation (Dear Sir/Mam, Mr./Mrs./Ms.)Body of the letter.Gratitude.Closing the letter (Your's Sincerely)Your Name and Signature.
I was treated in your office at your facility between fill in dates. I request copies of the following or all health records related to my treatment. Identify records requested, e.g. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals.
