ACCOUNT_FIRST_NAME  ACCOUNT_LAST_NAME

ACCOUNT_ADDRESS_SINGLE_LINE

ACCOUNT_PHONE_NO ACCOUNT_EMAIL

To  , 

ADDRESS

07 May 2024

Dear Sir or Madam, 

Re: Request for Medical Records - Ref. no:  

I am writing to request copies of my medical records as allowed by the AUTHORITY_APPROVE and LAW_APPROVE.

I was treated at your clinic from [date] to [date]. I would like to request to include all charts, test results, consultation notes and referrals regarding my medical care during this period. Please mail the requested records to me at the above address.

I understand I may be charged a reasonable fee for copying the records, but that I will not be charged for the time spent locating the records. I also understand that I will be charged for postage. 

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