chicago injury accident lawyers lamber

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.




{attorney’s name}

Arizona Personal Injury Complaints

Arizona Interpleader Actions

Arizona Discovery Documents

Arizona Pre-Litigation Documents

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.