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(Date of Letter)

(Hospital/Care Provider) (Street Address) (City, State and Zip Code) RE: Attn: Transfer of Records Office Administrator

Dear Office Administrator: From the day of day of care for circumstances, including (month/year), until the (month/year), your facility provided (name of individual). Due to specific

(list reasons or circumstances), it will be necessary for the aforementioned patient to be transferred to another facility for continued care. Therefore, arrangements should be made for the immediate transfer of the above-mentioned patient, along with an immediate transfer of all medical records to (name of new facility). Kindly provide transmittal copies of all records to the undersigned when the transfer of records occurs. Also, please advise the undersigned of the transfer date of the aforementioned patient so that the undersigned may make necessary arrangements, including the processing of any insurance payments or other payments that remain outstanding. Should you have any questions or concerns relative to the foregoing, kindly contact the undersigned. Thank you for your kind attention. Very truly yours,

(Signature) (Address) (City, State and Zip Code) (Phone Number)

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