Release of Medical Information Letter

You can use this release of medical information letter to get information about your medical procedures from a physician or an institute that has recently treated you.

[Reciever’s Name] 

[Reciever’s Address] 

[City, State, ZIP], 


[Sender’s Name], 

[Sender’s Address], 

[City, State, ZIP]

[Subject: Mention the purpose of writing the letter. Write in bold formatting to make text look more focused]. 

Dear [Reciever’s Name], 

I am writing this letter to request you provide access to my medical records present under the name of your practice/hospital. It is well in my information that the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations have provided me the privilege of having copies of my medical records. 

I vouch that you treated me in your facilities within dates [mention date-date]. I request you provide copies of all the records of the treatments you administered during these dates. Please also enlist any previous medical history I may have provided you, including test results and any consultations with the specialists. 

According to HIPAA, you must provide me with the requested medical records within 30 days. However, if it takes a longer time, kindly write me back stating that it will take longer. Please also mention the expected time by which I can receive my medical documents. I am also willing to pay a fee for copies and postage to my address. 

If you have any questions or need more information, call me at [Contact Number] or [email address]. 


[Sender’s Name]. 

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