Name Insurance Coverage In:
Plan #:
Family Name Covered Under Plan:
Individual Covered & Subject to This Letter:
Social Security Number of Individual:

To: Medical Office Manager

I am writing to request a copy of my medical records. Please send it to me at the address on this letterhead.

I was formerly a patient of Dr. __________. Enclosed is a signed Authorization to Release Medical Records. I am requesting the records for insurance-related reasons.

If there is a charge for copying the records, please submit a statement with the records and I will remit payment or charge it to my credit card number: ____________________ Expiration Date: _________; Under my name listed exactly as: __________________.

Thank you for your continued good service that I have received in the past.
Best regards,
____________
Writer

Enclosure: Authorization to Release Medical Records
Faxed and Mailed (Unless you can’t fax; if you cannot, then remove this notation).

Authorization to Release Medical Records, Cover Letter
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This is a benign request in the medical world. Therefore, be nice; clear; have your documents together for easy administration (the bane of all of these medical groups). At the end of the above letter, write a short handwritten note saying, “Thanks for your continued help; appreciate your fast response so I can get on with it.” This makes your request for speed less annoying and more personal at the same time. A double win.

The separate document for Authorization itself lends formality and precision to your approach. It is complete and suggests you know what you are doing, so they will want to get you off their hands more quickly than others that reach their in pile. Remember, in the medical world, the challenge is to get in their “A” pile that they attend to and stay out of their “B” pile that they do not! Amusing perhaps; but deadly accurate as a wise overall objective in the medical world. They have tons of paperwork to attend to; make sure you provide emotional (when possible), paperwork, and simplicity incentive for them to deal with you immediately.

Faxing and mailing it, as a backup, is the recommended approach. Delivers both immediacy and original signatures for them.

Some medical offices require you to fill out their own release forms. If so, we believe it more expeditious to just present them with yours, which may make them overlook their own bureaucratic tangle, and just release them. At a minimum, this approach won’t hurt; it will certainly let them know you have taken the request, and therefore “them,” seriously. Medical people like that. So you are ahead of the game giving them everything they need should they accept it. If they don’t, you can fill out their form and send it in virtually the same amount of time.

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