Authorization to Release Medical Records, Cover Letter

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Authorization to Release Medical Records, Cover Letter

Name Insurance Coverage In:

Plan #:

Family Name Covered Under Plan:

Individual Covered & Subject to This Letter:

Social Security Number of Individual:

To: Medical Office Manager

I am writing to request a copy of my medical records. Please send it to me at the address on this letterhead.

I was formerly a patient of Dr. __________. 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 or charge it to my credit card number: ____________________ Expiration Date: _________; Under my name listed exactly as: __________________.

Thank you for your continued good service that I have received in the past.

Best regards,

____________

Writer

Enclosure: Authorization to Release Medical Records

Faxed and Mailed (Unless you can’t fax; if you cannot, then remove this notation).