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: __________________
Medical Records Request Letter Template
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.
Legal · Updated July 7, 2026
Copy and download are free. Mailing options and prices.
Before you start
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
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.
Frequently asked questions
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.
This template is for informational purposes only and does not constitute legal advice. Consult an attorney for specific legal matters.
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