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Sample Doctor Letter Requesting Release of Medical Records

{Today’s Date}

Facsimile: {facsimile number}

{Name of Doctor Office}
Attention: Medical Records
{Entity mailing address, Line 1}
{Entity mailing address, Line 2}
{City, State Zip code}

Re:      Our Client/Your Patient:        {Client/patient name}
Date of Accident:                    {xx/xx/xxxx}
Social Security No.:                {xxx-xx-xxxx}
Date of Birth:                          {xx/xx/xxxx}

Dear Medical Records Administrator:

{Client/Patient Name} has retained this law firm/office with respect to injuries {he/she} sustained as a result of an accident on the above-referenced date. In order to handle this {claim/case} properly, we are requesting copies of the following:

  • All records, cover-to-cover, in your file/chart from the date of the subject accident to the present date.
  • Itemized statement showing all charges for all services from the date of the subject accident to the present date.

Enclosed, please find a signed HIPAA release authorization form that allows this firm to receive the requested information. Please forward this information to us at your earliest convenience. Faxed copies are acceptable.

If you require prepayment, please send an invoice for prompt payment.

Thank you for your assistance in this matter.




{attorney’s name}

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Disclaimer: The information and forms on this site are for illustrative purposes only. The information is not intended to be used by anyone other than a licensed Arizona attorney familiar with Arizona personal injury law. The forms and the information contained in them may not be up-to-date and must be independently reviewed, cite checked, rule checked, and otherwise verified by a licensed Arizona attorney. The information contained in the forms on this website cannot and must be relied on for the purposes of filing legal documents or otherwise pursuing a claim. If you have any questions about this, please contract and attorney at or by calling 602-833-1274.