Medical Records Request Letter Template
Updated July 7, 2026 | Legal
Use this medical records request letter template to ask a doctor, clinic, hospital, or records department for copies of your health records. It is structured for a signed request with enough detail to identify the patient and the records requested.
Quick Answer
A medical records request letter should identify the patient, the provider, the records requested, the date range, the delivery method, and your signature. Best for: requesting copies from a provider or facility. Include: patient name, date of birth, date range, record types, and delivery address. Mail it when: the provider requires a signed authorization or you need proof of request.
When to Use This Medical Records Request Letter Template
- Requesting records from a doctor
- Getting hospital records
- Sending records to a new provider
- Requesting billing or visit notes
- Documenting a records request
- Following up on a delayed request
Medical Records Request Letter Template
The Letter Pilot
Mail-ready template
Verification letter
MEDICAL RECORDS REQUEST LETTER
[Your Name]
[Your Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
[Date]
[Provider or Facility Name]
[Medical Records Department]
[Mailing Address]
[City, State, ZIP Code]
Re: Request for Medical Records
Patient name: [Patient Full Name]
Date of birth: [MM/DD/YYYY]
Patient account or MRN, if known: [Number]
Dear Medical Records Department:
I am requesting copies of medical records for the patient listed above.
Records requested:
[Describe the records, such as visit notes, test results, imaging reports, billing records, discharge summary, or complete medical record.]
Date range:
[Start date] through [End date]
Please send the records by:
[ ] Mail to the address above
[ ] Secure email to: [email address]
[ ] Fax to: [fax number]
[ ] Other: [instructions]
If a fee, authorization form, or additional identification is required, please contact me at [phone number] or [email address].
Thank you.
Sincerely,
[Your Signature]
[Your Printed Name]
Enclosures:
- [Copy of identification, if required]
- [Authorization form, if required]
SENDER'S RECORD:
Date sent: __________________
Sent by: [ ] Certified Mail [ ] Other tracked mail
Tracking number: __________________
Follow-up date: __________________
Need to mail this with tracking? The Letter Pilot handles postage, tracking, and Certified Mail options online.
How to Use This Medical Records Request Letter Template
- Identify the patient. Include the patient name, date of birth, and account or medical record number if known.
- Name the records. State whether you need the complete record, visit notes, test results, imaging reports, billing records, or another specific record type.
- Add a date range. A date range helps the records department find the right documents faster.
- Choose delivery method. Tell the provider whether to mail, email, fax, or otherwise send the records.
- Sign and track the request. If mailing, sign the request and keep the tracking number with a copy of the letter.
Mailing and Recordkeeping Tips
- - Keep the tone direct, factual, and professional.
- - Use copies of supporting documents unless originals are specifically required.
- - Save the completed letter, attachments, mailing receipt, and tracking number together.
Medical Records Request Letter Template FAQ
How do I request medical records in writing?
Identify the patient, provider, records requested, date range, delivery method, and contact information. Sign the request and include required authorization documents if needed.
Can I mail a medical records request?
Yes. Many providers accept mailed requests, especially when a signature or copy of ID is required. Check the provider instructions first.
Should I include my date of birth?
Yes. Date of birth helps the provider identify the correct patient, especially when patients have similar names.
Should I send original ID documents?
No. If identification is required, send a copy unless the provider specifically requires another process.
What should I keep after sending the request?
Keep a copy of the signed letter, attachments, mailing receipt, tracking number, and any response from the provider.
Legal Advice Disclaimer: This template is for informational purposes only and does not constitute legal advice. Consult an attorney for specific legal matters.
Related Templates & Guides
Ready to mail the final letter?
Customize this template, then continue to online mailing with tracking.