Medical Records Request Letter (Template)

From Unveiling Unicorns — educational information only. This template is not legal advice.

(Your full name)

(Your address)
Phone:   Email:

(Date)

(Medical Records Department)
(Provider / hospital name)
(Address)

Re: Request for medical records — Patient: , DOB:

To whom it may concern:

Under the HIPAA Privacy Rule's right of access (45 CFR § 164.524), I am requesting copies of the following medical records:

Complete medical record for dates of service from to
Specific records only: (e.g., cardiology notes, lab results, imaging reports)

Please include: office/clinic notes, test and lab results, imaging reports, procedure and operative reports, discharge summaries, medication lists, and correspondence related to my care during the dates above.

Preferred format: paper copies   electronic (email/USB)   patient portal

I understand you may charge a reasonable, cost-based fee for copies. Please inform me in advance if the fee will exceed $.

Please send the records to:
(name/address, or "to me at the address above")

Thank you.

Sincerely,

(Signature)

(Printed name)    Date:

Relationship to patient (if not self):

Know your rights

  • Under HIPAA, providers must respond to your request within 30 days (with one possible 30-day extension, explained in writing).
  • You have the right to get your records in the electronic form and format you request, if readily producible.
  • Fees must be reasonable and cost-based — many states cap them.
  • A provider cannot deny your request because of an unpaid bill.
  • If requesting for your minor child, you generally have the right as the parent/guardian; for adult children or others, you may need a signed authorization or legal authority (guardianship, healthcare proxy).

Tips

  • Keep a copy of the signed request and note the date you sent it.
  • If you need records urgently (e.g., for a disability appeal deadline), say so in a cover note and follow up by phone.
  • Request records from every provider separately — hospitals do not share record systems with outside clinics.

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