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How to fill out a health or medical record release form Patient information. Whose health records do you want? ... Clinic, hospital, care provider. ... Date of Services. ... Information to be released. ... Receiving party or destination of records. ... Purpose of release. ... Expiration date or duration of consent. ... Release instructions.
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 filled out; physician and nurses' notes; test results; consultations with specialists; referrals).]
Here is how to write a request letter in 7 steps: Collect information relating to your request. ... Create an outline. ... Introduce yourself. 4. Make your request. ... Explain the reason for the request. ... Offer to provide additional information. ... Show your gratitude and conclude the letter. ... Use a professional format.
6 Steps to Write a Medical Request Letter Step 1: Receiver Details. The first section in a request sample letter to start with is the details of the receiver to whom you are sending the letter. ... Step 2: Salutation. ... Step 3: Reason. ... Step 4: Hospital Details. ... Step 5: Gratitude. ... Step 6: Closing Signature.
Keep the letter brief, clear, readable and relevant. Less is more. Avoid different types of emphasis ? e.g. CAPITALS (shouting!), bold and italics.