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(Date of Letter)

(Hospital/Care Provider) (Street Address) (City, State and Zip Code) RE: Attn: Request for Medical Records Medical Records Department

Dear Medical Records Department: day of day of provided certain medical care for of individual). This care involved treatment for From the (month/year), until the (month/year), your facility (name

(description of condition for which treatment was received), during which various medical records were prepared and maintained. It is respectfully requested that copies of all medical records be provided relating to the aforementioned care, including: initial consultation, history, examination, tests, diagnosis, nurses' notes, physicians' notes, summaries, laboratory reports, test reports, x-rays, CAT scans, EKGs, EEGs, treatment and prognosis. The complete records will be necessary in order for my files to be satisfied. Any specific observations or assessments contained within your files relative to the aforementioned care would also be appreciated. Should you have any questions relative to this request, please contact the undersigned. Kindly note a current patient waiver form for the release of the requested records is enclosed. Thank you in advance for your fulfillment of this request. Very truly yours,

(Signature) (Address) (City, State and Zip Code) (Phone Number) LAWCHEK, LTD. LETTER PRO Samples, Copyright 2000 This is not a substitute for legal advice. An attorney must be consulted.