The record request, ready to move the case.

October 14, 2026

[Records Custodian]
[Custodian Address]

RE: Request for Medical Records
Patient: [Patient Name]
Date of Birth: [DOB]
Date of Incident: [Date of Incident]

Dear Records Custodian:

This office represents the above-named patient in connection with injuries sustained on [Date of Incident]. Please accept this letter as a formal request for a complete and certified copy of all medical records pertaining to the patient for the period of all dates of treatment.

The records requested include, but are not limited to: history and physical examinations, physician and nursing notes, consultation reports, diagnostic imaging reports and films, laboratory and pathology results, operative and procedure reports, therapy notes, discharge summaries, prescription and medication records, and an itemized billing statement with applicable CPT and ICD codes.

A signed authorization for the release of protected health information is enclosed. Please produce the records within the timeframe required by applicable state and federal law. If any fee is required to process this request, please contact our office before incurring charges in excess of any statutory limit.

If you maintain that any portion of the requested records is unavailable or privileged, please identify the records withheld and the basis for withholding them.

Thank you for your prompt attention to this matter.

Sincerely,

[Requesting Party / Firm]
[Requesting Party Address]

Enclosure: HIPAA-compliant authorization