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You can use the letter below as a template I designed for asking a release of your psychiatric records.  Copy and paste it to a word processer.  Replace all the Red with Your Information.    Kathi Stringer

 

 

From the Desk of Your Name

Your Address               (xxx) xxx-xxxx

 

TO:  The Hospital Name
Address Line 2

Address Line 3

Main Phone - (xxx) xxx-xxxx

Records Administrator: Name Here

Medical Records: (xxx) xxx-xxxx

Fax: (xxx) xxx-xxxx

 

Today's Date Here

 

Request Full and Complete Medical Records

For: Your Name 

Medical ID: If known             DOB: xx/xx/xxxx                      SSN: xxx-xx-xxxx

 

As per my conversation with contact person at Hospital Name medical records on date, and per this written authorization, you are hereby authorized to release a complete comprehensive copy of the medical records as to the history, psychiatric and/or physical condition, and/or treatment to Your Name (myself).

 

The medical information sought is for the specific use of Your Name for abuse relating to injuries, benefits, corrective action, Title 22 compliance referencing, and/or other matters relevant for auditing and reference.

 

This release applies to all documents, records, reports, photographs, billings, studies, interoffice memos, or correspondence relating to the treatment, examination, or hospitalization, including but not limited to all physical or psychiatric conditions (seclusion/restraint checklist, legal advisements, doctor’s orders, doctors notes, progress notes, 24 hour head count, intake dx/symptoms, discharge summary, psychologist reports, multidisciplinary notes, nursing progress notes, record log of all staff present while inpatient, medication charts/records, denial of rights for good cause check list, transport records; etc.) – complete record.  Please use the dates below for reference.

 

Admit Dates in: Date Here                     Discharge Dates: Date Here

 

Once the records are ready, please advise for pickup/willcall.  I may be reached at Cell - (xxx) xxx-xxxx.  Thank you for your efforts and attention with this matter.

 

Sincerely,

 

Your Name Here

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Next is a template for a letter receipt if you want to deliver the request for records yourself.  Use the template below and have whoever accepts the records request letter sign for it.

 

From the Desk of Your Name

Your Address               (xxx) xxx-xxxx

 

TO:  The Dept Name
Address Line 2

Address Line 3

 

Attn: Records Person Name

Subject:: Request Full and Complete Medical Records

 

 

LETTER RECEIPT

 

 

Attn: Dept and Person Name

Subject: Request Full and Complete Medical Records

 

Date Here

 

Received a 1- page letter from Your Name Dated Today's Date

 

X_________________________________________

 

 

X_________________________________________



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