Medical Records Form Printable

Dear Recipient's name, I am writing you to request copies of my medical records. I was treated in your office on xx/xx/xxxx. Please include all of my charts, test results, and consultation notes including referrals regarding my medical care.

Details of the patient such as name and address. Name of the doctor. Purpose of the appointment. Requested date and time of the appointment. Any previous history with the doctor or any other doctor. Name of your health insurance plan.

You can formally request specific information from the Ministry of Health. In limited circumstances, access to information will require a formal access application. A copy of an application form that you may use to request information held by the Ministry of Health is available.

Explain precisely what your request is. Mention the reason for the request. Use polite language and a professional tone. Demonstrate respect and gratitude to the reader. The content of the letter should be official. You may provide contact information where you can be reached.

To access your information, write to the relevant health service to make a data access request. You may be asked to provide evidence of your identity. If you are making an access request to a HSE service (pdf), you can write to the health service or send it a HSE Subject Access Request Form (pdf).

Explain precisely what your request is. Mention the reason for the request. Use polite language and a professional tone. Demonstrate respect and gratitude to the reader. The content of the letter should be official. You may provide contact information where you can be reached.

Write "Dear Dr." and the doctor's last name on the top line of the letter itself. For example, begin your message with, "Dear Dr. Williams." Use this prefix for those with doctorates, too, unless the person has specifically told you to avoid doing so.

Your full name. The full name of the person responsible for handling the request for data. Date requested. Type of information requested. Any relevant names. The reason for the data. How you will use the data.