[Date]
Via Facsimile
Children’s Hospital
200 Henry Clay Ave
New Orleans, LA 70118
Attn: Release of Information
Fax: 504-896-9214
RE: [Patient Name] (DOB: XX/XX/XXXX) – Request for Medical Records
Dear Sir or Madam:
Please accept this letter as a written request on behalf of my client, [Parent Name], to request all medical records currently in the possession or control of the New Orleans Children’s Hospital that relate to her child, [Patient Name]. A HIPAA Release for these records executed by the parent/guardian is enclosed herein.
This request is for [Patient Name]’s entire medical and mental health records, including but not limited to: all treatment plans, physician’s and treating practitioner’s notes (handwritten and/or typed), therapy records, emergency records, medical reports, progress notes, lab work, copies of prescriptions, copies of consultations, referrals, x-rays, correspondence, discharge summaries/documents, and all other health records.
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.
We ask that all records be provided by [Insert Reasonable Date] Thank you in advance for your assistance and quick response. I can be reached by email at [Email Address] or by phone at (XXX) XXX-XXXX.
Sincerely,
[Requestor Name]
[Title]
Encl. – HIPAA Release Form