_________________________, 20___
							(Date of Letter)


______________________________
(Hospital/Care Provider)
______________________________
(Street Address)
______________________________
(City, State and Zip Code)

RE:	Request for Medical Records

Attn:  Medical Records Department

Dear Medical Records Department:

	From the ______ day of ___________________________________, _____(year),
until the ______ day of ___________________________________, _____(year), your
facility provided certain medical care for ________________________________________
(name of individual).  This care involved treatment for ___________________________
_____________________________________________________ (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 (our) 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 2006
This is not a substitute for legal advice.  An attorney must be consulted.