Medical Records Request Letter

Please enter your information in the form and email them to your former Physician.

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To Whom It May Concern:

I am writing to request a copy of my medical records, preferably via email, otherwise, regular mail.

I was formerly a patient of (required) .

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 upon receipt of the records.

Thank you for your attention to this matter

Sincerely,

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