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I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested, e.g. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals.] [Note: HIPAA also allows you to request a summary of your medical records. If you prefer a summary, you should agree to a fee beforehand.] I understand you may charge a ireasonablei 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 address...
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