The authorization letter to get medical records is the word template for requesting the medical records. This authorization letter is signifying that you give permission for the third party or authorized party in the letter to receive your medical records.
This authorization letter to get medical records template has several elements:
The part where you enter your details. The fields are:
- Your Name
- Street Address
- City, State, and Zip Code Address
- Date: when this authorization letter to get medical records is written and given.
The part where you enter your doctor details, which this authorization letter to release medical records will be given to. The fields are:
- Doctor Name
- Clinic or Hospital Name
- Clinic or Hospital Street Address
- Clinic or Hospital City, State, and Zip Code Address
On this template content, you may find the sample letter to release medical records context. You can simply write your own letter content.
The grey text is the placeholder that you supposed to change. The content itself has several parts:
- Subject or Title: tell about the request title, your full name, Date of Birth, and SSN. If you live outside US, you can change the SSN into Identity Card Number or Patient ID.
- Content Opening: it opened with greeting words. In this opening, tell about your medical condition that has been treated before and the date of the treatment.
- Third Party: The party which you give authorization to receive and see your medical letter. It include the organization or individual name, Street Address, and City Address.
- Content Closing: tell about thank you, and inform to pay the cost of medical copies.
This is where you place your signature or anything as proof that you write the letter and give the authorization to release medical records to third party. It consist of the closing greetings, and your name. The Name field is autogenerated.
HOW TO USE
To use the authorization letter to get medical records, simply replace the placeholder text with your own information. Follow the rules and tips to write a good authorization letter.
It is advised to write the content in less than 5 paragraphs and not too long. The content should be short and direct but polite. You should enter the important elements like the ones provided in authorization to release medical records form sample.
Modifying authorization letter to get medical records template is possible. Due to formality, it is not suggested to change the format even the text font, size, or color. Adding picture or watermark is not necessary at this point. You can make the text alignment to Justify through or add subheadings if it really needed. You can add company header if the medical record is requested by your company.
Here is other sample authorization letter to pick up medical records, in content only:
I am writing this letter to request copies of any medical records of mine that you have. I have understood that according to the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations, I am entitled to have copies of my medical records.
I was treated in ABC Hospital from 21 June 2016 to 30 June 2016. I would like copies of all of my blood test results, imaging studies, operative reports, as well as notes from doctors and nurses, consultations with specialists, referrals and any other record in my medical file.
I understand you may charge a reasonable fee for copying the records, as well as for postage to mail the reports to the above address. However, you will not charge for time spent locating the records.
I hope to receive the above records within 30 days as specified under HIPAA or receive a letter stating the reason for any delay. I can be reached at (123) 123-4567 or a firstname.lastname@example.org if you have any questions.
Thank you for your attention.
To download authorization letter to get medical records, click one of these:
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