If my request cannot be honored within thirty days, please inform me of this by letter and provide the date by which I might expect to receive my records. I look forward to receiving the above records within thirty days, as specified under HIPAA. Please mail the requested records to me at the above address. I am glad to inform you that the screening test for medical conditions are NEGATIVE. Dear Sir or Madam, I am writing you this letter to inform you of the results of the recent tests performed by laboratory name for medical center name. Laws and regulations require that some sources of personal information have a signed authorization or permission form before releasing it. Given below is an example of patient notification for test results. I understand that you may charge a “reasonable” fee for copying the records but will not charge for time spent locating the records. Explanation of Form Florida AHCA FC4200004 Universal Patient Authorization for Full Disclosure of Health Information for Treatment & Quality of Care. ![]() I request copies of the following health records related to my treatment. Receiving doctor Name, I hope this letter finds you in the best of health and high spirits. ![]() ![]() The purpose of this letter is to request copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations. Sample Letter to Healthcare Provider for Your Records A HIPAA release form must be obtained from a patient before their protected health information is disclosed for any purpose other than those detailed in 45 CFR 164.506, which are specifically covered in 45 CFR 164.
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