Patient letters
Pick the letter that fits, fill in the blanks, then copy or download it. Everything stays on your device — nothing you type is sent or saved. These are templates, not legal advice.
Not sure which letter you need? See the Patient Letter Hub. Appealing an insurance denial? Use the appeal letter builder. Asking for charity care? Use the financial assistance letter.
Medical records request for an appeal
- Law:
- HIPAA right of access, 45 C.F.R. §164.524
- Timing:
- Generally 30 days to respond (one 30-day extension allowed). Fees must be reasonable and cost-based.
- Send to:
- The provider’s medical records or privacy office.
Your letter
[Your name] [Your address] [Date] [Recipient name and address] Re: Request for access to medical records Account/Reference: [Account number] Date of birth: [date of birth] Under 45 C.F.R. §164.524, I request a copy of my medical records for [dates of care], including visit notes, test results, orders, and any records used to support the claims for this care. I am requesting these to support an insurance appeal. Please provide them electronically if available. Please tell me in advance of any fee. Sincerely, [Your name]
Keep a copy and send by certified mail with return receipt when you can. Replace anything in [brackets] before sending.