Ask for your medical records
A written request to your doctor, hospital or clinic for a copy of your own medical record under the federal health privacy rule, for use in your appeal.
- Private: nothing leaves this tab
- A template, not legal advice
When to use this, and what it is not
When to use this. Use this to get the records that show why you needed the care. Send it to the provider's medical records or health information department, not the billing office. Many offices have their own request form; ask for it too and send both.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the provider's medical records office]
Re: Ask for your medical records Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am a patient of [Doctor, hospital or pharmacy]. My name is [Your name] and my date of birth is [Your date of birth].
I am asking for a copy of my medical records under my right of access to my own health information under the federal health privacy rule, the Health Insurance Portability and Accountability Act (HIPAA).
Please send me my complete medical record for [The dates you want records for] about [What the records are about]. This includes visit and progress notes, test, laboratory and imaging results and reports, medication lists, treatment plans, referral letters, and any letters or forms sent to or received from my health plan, [Name of the health plan].
The privacy rule requires a provider to act on a request for an individual's own records within 30 days. It allows one extension of up to 30 more days if the provider explains the delay to me in writing. It allows only a reasonable, cost-based fee for copies. If you charge a fee, please tell me the amount before you copy the records.
Please send the copy [How you want the copy]. I need these records for a health insurance appeal. If you can send them sooner than 30 days, I would be grateful. If your office uses its own request form, please send it to me at once and I will return it the same day.
Please confirm in writing the date you received this request and the date you send the records, so that I have proof of delivery.
Enclosures: 1. A signed copy of your office's own request form, if it has one
Sincerely, [Your name]
Before you send it
Send it to the medical records or health information department of the provider. Get the fax number, address or portal from the provider's front desk or website; do not guess. To prove it arrived, use certified mail with a return receipt, or fax it and keep the confirmation page, or send it through the provider's portal and take a screenshot that shows the date. If you hand it in, ask for a dated receipt.
What to enclose
- A signed copy of your office's own request form, if it has one
What happens next
- You: send the letter and the office's own form if it has one. Keep the proof of delivery.
- Provider: has 30 days from your request to act, with one extension of up to 30 more days if it explains the delay to you in writing. The privacy rule allows only a reasonable, cost-based copying fee.
- You: write day 30 on your calendar. If the records have not come, call the records department, ask for the status and write down the date, name and any reference number.
- You: your insurance appeal deadline keeps running while you wait. Your appeal deadline depends on your coverage and is printed on your denial notice. For most job-based and individual plans it is at least 180 days after you receive the notice. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different deadlines, often shorter, and they are on your notice. Check the date on your notice, which controls.