Sample Medical Information Letter

You can use this Sample Medical Information letter to ask for your medical request from a hospital or an institute that has recently treated you.

[Sender’s Name] 

[Sender’s Address] 


[Name of the Institute] 

[Institute’s Address] 

[Subject: Mention the subject here in bold formatting],

Dear [Reciver’s Name], 

I am writing you this letter to request copies of my medical records, pursuant to my rights as depicted by the Department of Health and Human Services Regulations. 

This letter confirms that I received treatment from you in your office [mention the institute’s name] on the dates [Mention the dates of your treatments]. Consequently, I request you to provide me the copies of all medical procedures carried out on the mentioned dates. 

I understand the institute may charge me a fee for copying the records, and I am compliant. Nevertheless, I will not comply and pay for the time spent finding the records. 

I request that you send the required documents to the address mentioned above at the earliest. I shall remain thankful for your services and for considering my request to provide me with the required medical information. 


[Sender’s Name]

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