Medical Records Request

________
________

________

________
________

RE: Medical Records Request for ________

Dear ________,

I am a current patient of ________ asking that you provide me with a copy of my medical records from your practice. I am requesting my medical records for reasons related to my health insurance.

I have included a signed Authorization of Medical Records Release form with this letter. If there is a charge associated with releasing these medical records, please submit a billing statement with the records and payment will be remitted promptly upon receipt of the records. If you need any further information from me, you may contact me in the following manner:

________

Thank you for your attention to this matter.

Best,

________

Enclosure

AUTHORIZATION OF MEDICAL RECORDS RELEASE

1. Patient Information.

Name: ________
Address: ________
SSN:_______________________
Date of Birth: ________

2. Authorization for Release.

I, ________, hereby authorize the following individual at the following address:

________
________

to release, disclose, and deliver the medical information described below to the following individual:

________
________

3. Specific Authorization.

I specifically authorize the release of only the following information:

________

I do not give permission for any other use or redisclosure of this information.

_________________________________
________


_________________
Date

4. Redisclosure.

This release does not authorize redisclosure of medical information beyond the limits of this consent. The Recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party without further authorization. The following written statement should accompany certain disclosures:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2 and 45 CFR Parts 160 and 164). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and 45 CFR Parts 160 and 164. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

I specifically understand and agree that the redisclosure requirements set out above will apply to these records.

5. 55885822.

5 5252582525 2552 2588 5525258252822 8888 5522252885882 252852 222 2255 2522 252 5522 22 22 882252552, 525 2552 5 252 528222 2588 5525258252822 82 8225822 5 8582222 222882 22 252 225822 25 222822 5525258225 22 2522 252 5888828552 528858825 58282. 5 52522 2552 522 5282582 85885 558 8222 2552 25825 22 5282852822 525 85885 858 2552 82 52885282 52222 2588 5525258252822 85588 222 8228282522 5 852585 22 22 582528 22 822285222858822.

I authorize the release of information as indicated above.

_________________________________
________

_________________
Date