[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Healthcare Provider's Name] [Healthcare Provider's Address] [City, State, ZIP Code] Subject: Request for Medical Records Dear [Healthcare Provider's Name], I hope this letter finds you well. I am writing to request a copy of my medical records from your facility in accordance with the laws and regulations governing access to personal health information. I am a resident of North Dakota and have received medical care, diagnoses, treatments, and procedures from your healthcare provider within the past [insert time frame]. It is my right as a patient to have access to my medical records, as stated in the North Dakota Health Information Privacy Act. Kindly provide me with a complete copy of my medical records, including: 1. Consultation notes 2. Progress notes 3. Lab/test results 4. Radiology reports 5. Medication records 6. Surgical reports 7. Allergies and immunization records 8. Treatment plans 9. Discharge summaries 10. Any other relevant documents pertaining to my healthcare I understand that there may be fees associated with acquiring my medical records. If there are any charges, please inform me beforehand and provide an itemized invoice for the same. If the fees exceed the limits specified by North Dakota law, please let me know if any alternatives can be explored to reduce the cost. To ensure prompt processing of this request, I have enclosed a completed Authorization for Release of Medical Information form as required by your facility. Along with the form, please find a copy of my valid ID [if applicable] to verify my identity. If you have any questions or require any additional information, please do not hesitate to contact me at [provide your preferred contact details]. I request that my medical records be provided to me within the time frame stipulated by North Dakota law. If for any reason you are unable to fulfill this request, please inform me promptly in writing, along with an explanation. Thank you for your attention to this matter. I greatly appreciate your cooperation and assistance in ensuring I receive the necessary medical records. I look forward to your prompt response. Sincerely, [Your Name]
North Dakota Sample Letter for Request for Medical Records
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How to fill out North Dakota Sample Letter For Request For Medical Records?
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To write a letter of request, start by greeting the recipient with Dear, followed by the person's last name and title, or To Whom It May Concern. Then, briefly explain who you are and why you're writing in the 1st paragraph. Next, provide additional context and details about your request in the 2nd paragraph.
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.
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...
Can I view my medical records? Yes. You have a legal right to see your own records. You do not have to explain why you want to see them.
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...?
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...
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.
