Medical Records Request Letter, Free Download 2026

DATE: [____________]. TO: [Provider / Facility Name: ____________], Attn: Health Information Management / Medical Records Department, [____________] (Address). FROM: [Patient Full Legal Name: ____________], [____________] (Mailing Address), [____________] (Phone), [____________] (Email). RE: Request for Access to Medical Records. Patient Date of Birth: [____________]. [Former name(s) records may be filed under: ____________.] [Medical Record No. / Patient ID, if known: ____________.] [Approximate dates of treatment: ____________.]

I am the patient identified above [or: I am the personal representative of the patient identified above, and documentation of my authority (such as a healthcare power of attorney, guardianship order, or proof of parental status for a minor) is enclosed]. Pursuant to my right of access under the HIPAA Privacy Rule, 45 CFR 164.524, I request access to and copies of my protected health information in your designated record set, as described below. This is a request for my own records; it is not an authorization to disclose my records to a third party.

Please provide the records indicated below [check all that apply] for the period from [____________] to [____________]: [ ] Complete medical record / designated record set; [ ] Office visit and progress notes; [ ] History and physical examinations; [ ] Consultation reports; [ ] Operative and procedure reports; [ ] Discharge summaries; [ ] Laboratory and pathology results; [ ] Imaging reports (X-ray, MRI, CT, ultrasound) [and the underlying images on disk or via electronic transfer]; [ ] Medication and prescription records; [ ] Immunization records; [ ] Billing and itemized statement records; [ ] Other: [____________].

I request the records in the following form and format [check one]: [ ] Electronic copy (PDF or other readily producible electronic format), delivered by [secure email to: ____________ / patient portal / CD or USB mailed to my address above]; [ ] Paper copies mailed to my address above; [ ] I will pick up the records in person [I will present government-issued photo identification]. If you maintain the requested records electronically, I ask that you provide them in the electronic form and format I have requested if readily producible, as provided by 45 CFR 164.524.

I understand that you may charge a reasonable, cost-based fee for copies, limited to the cost of labor for copying, supplies (such as paper or electronic media), and postage, as permitted by 45 CFR 164.524. Please notify me in advance at the phone number or email above if the total fee will exceed [$________], so that I may confirm or narrow this request before you fulfill it.

Under 45 CFR 164.524, a covered entity must act on a request for access no later than 30 days after receipt, and if it is unable to act within that period, it may extend the time by no more than 30 additional days by providing me a written statement of the reasons for the delay and the date by which it will complete action on the request. [Some state laws require a faster response; this request incorporates any shorter deadline applicable under the law of your state.] If any portion of this request is denied, please provide a written denial including the basis for the denial and a statement of my review rights. Please contact me at the phone number or email above if you require additional information or a signed patient verification form to process this request. Thank you for your prompt attention.