Simply replace the unfilled areas such as "" and "[date]" with your information.
Please accept this letter as a written request for medical records regarding your patient, [Patient]. Please note that we are requesting any and all medical records currently in the position of your office regarding [Patient], up to and including all physician's notes, lab work, copies of prescriptions and treatment plans, copies of consultations, and x-rays.
We have attached a signed Waiver from [Patient] releasing these medical records to us.
Should your office charge to copy these records, please notify us in advance of the fee per page, and the number of pages that will be copied.
Thank you for your prompt attention to this matter.