Free letter template
HIPAA medical records request letter
Request copies of your health records from a provider or health plan.
Recommended: Certified + return receipt ($17.99)The 30-day deadline runs from receipt.
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Re: Request for access to my health records
To [Provider or plan]: Under my right of access under HIPAA (45 CFR 164.524), I request copies of [Records requested]. Name: [Your name] Date of birth: [Your date of birth] Please provide the records as [Format and delivery]. Please tell me in advance if there is a fee. Sincerely, [Your name]
When to use this letter
- You need your records for a new doctor, an appeal or a claim
Where to send it
The provider's medical records / health information management office.
Tips before you mail it
- Include a copy of your ID if the provider requires it.
- If the provider has its own form, upload that instead.
The full template text
Re: Request for access to my health records
To {{provider}}:
Under my right of access under HIPAA (45 CFR 164.524), I request copies of {{records}}.
Name: {{signature}}
Date of birth: {{dob}}
{{patientId}}
Please provide the records as {{format}}. Please tell me in advance if there is a fee.
Sincerely,
{{signature}}Text in {{double braces}} is filled in from the form above. This is a general template, not legal advice.