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| Request for Medical Records Name: (enter your name here) D.O.B: (enter date of birth here) SS #: (enter Social Security # here) Patient Signature:________________________________________________ I am writing to request my medical records. Please fax (preferred) or mail them to the following numbers and/or addresses: Surgeon's Name Surgeon's Department (if neccessary) Surgeon's Address Office Number: (555)321-9000 Fax Number: (555)321-9001 Your Name Your Address Home Phone: (555)321-9002 Work Phone: (555)321-9003 Fax Number: (555)321-9004 I am also enclosing a photocopy of my Driver's License for signature verification purposes. I thank you for your time! Sincerely, (sign here) Your Name |
| If you know your patient ID number, by all means, add that to it. I did not have to include my license because the doctor's that I requested records from were current doctors that knew me, or past doctors that remembered me. To make changes to this, just copy and paste into a program like Word! If you have access to a fax machine, that is very helpful! I had alot of the doctors just fax me my records, and then I was able to fax them myself to my surgeon's office. He still wanted copies directly from the other doctor's, but in the meantime he was able to look over the records. Also it is nice for your own well-being to have copies of your records. I looked over mine and highlighted info I thought would support my request for approval for my surgery. Also, make sure you ask if there is a fee for the records to be sent. Usually it is free from doctor to doctor (professional courtesy) but they might charge you something. Out of the 5 doctors I asked for records from, I only had to pay one fee ($6). |
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