Medical records, Clifford Ray Hackett
3659745@gmail.com
phone 671-787-2345

The purpose of this letter is to request copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations.

I was treated in your facility in 2007 and I request copies of all health records related to my treatment including but not limited to: physician and nurses’ notes; test results, consultations with specialists; referrals. I prefer a summary

I understand you may charge a ìreasonableî fee for copying the records, but will not charge for time spent locating the records. Please mail the requested records to me at the above EMAIL address.

I look forward to receiving the above records within 30 days as specified under HIPAA. If my request cannot be honored within 30 days, please inform me of this by letter as well as the date I might expect to receive my records*.

Sincerely,

Clifford Ray Hackett