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Sample Hospital Letter Requesting Release of Hospital Records

{Today’s Date}

Facsimile: {hospital facsimile number/mail only if hospital does not accept faxed requests}

{Name of hospital}
           Attention: Release of Information
           {Hospital mailing address, Line 1}
{Hospital 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 Records Custodian:

{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 patient’s file/chart including but not limited to: Air Evacuation or any other flight ambulance, ground ambulance with records/reports, admission and discharge reports, radiology reports, physician reports, operative reports, notes (handwritten and typed) from date of accident to present date.
  • Itemized statement showing all charges for all services from date of accident to present date.

Enclosed find a HIPAA release authorization signed by our client/your patient that allows this firm to receive the requested information. Please forward these records 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.

Sincerely,

{YOUR LAW FIRM NAME}

 

{attorney’s name}