To use this, copy and paste these two pages into a Word Document, fill in with the appropriate information in the blanks and send to anyone who might have your medical records. Send separate copies to the Home, if they are still there, the agency or attorney that handled the adoption, the physician that delivered your child, and the hospital where you delivered. Keep a copy of the form, and record the date that you send it.

Consider sending it “Return Receipt Requested” from the post office, which only costs a few cents, but is proof that it was received. There is a maximum amount of time in which your HIPAA request must be honored, so this step also insures that you have proof of they are in violation.

Each state has a fee that they allow for copying, so check your states laws in this regards. The fees are minor, usually no more than $25.00 or so. Keep calling, be persistent and don’t take ‘NO’ for an answer. Make them prove that they don’t have your records.

*****PAGE 1*****

[current date]


Attention: Medical Records—Release of Information


[city/state, zip]

Re: Your patient: [your name] (f.k.a. [list any former names])

Date of Birth: [date]

Social Security Number: [number]

Dear Sir or Madam:

This letter is written to request medical records of [YOUR NAME], formerly known as [your maiden name, or any other names you might have gone by—this helps them to locate you easier] during my childbirth on [DATE].

Please provide a complete copy of my medical records file, from cover to cover, including all reports, consultations, nursing notes, MD notes or orders, history questionnaires, prenatal records, or any other records in the file. This record may be on microfilm or microfiche. Please check all sources for my records.

According to HIPAA, Section 164.524, I am invoking my rights to obtain a complete copy of my medical record. Enclosed please find a HIPAA compliant authorization to release my medical records to me.

Please let me know via FAX [YOUR FAX NUMBER] or email at [YOUR EMAIL ADDRESS] if you incur any charges in filling this request and you will be promptly reimbursed.

Thank you for your attention in this matter.

Very truly yours,

[your name]

/[your initials]


*****PAGE 2*****


TO: [name of hospital]

SPECIFIC INFORMATION REQUESTED: a complete copy of my medical records file from cover to cover, including all nursing or MD notes, orders, diagnostic test reports, history questionnaires, prenatal records, or any other records in this file.

PURPOSE OF THE REQUEST: my personal use


(DOB: )

(SSN: )

You, and any person associated with you, are hereby authorized to give to: [MY NAME], any and all information which may be requested regarding my physical condition and treatment rendered by you.

I understand that I have the right to revoke this authorization, in writing, except to the extent that the provider has previously provided information. I understand that pursuant to the HIPAA Privacy Regulation, no treatment, payment, or eligibility for benefits from a covered entity has been conditioned upon the execution of this authorization. I understand that if the provider is covered by the HIPAA Privacy Regulation, once the provider discloses the protected health information, it may no longer be protected by the regulation.

A photocopy of this authorization shall serve in its stead. This authorization expires in one year from the date of the authorization.

Legal Signature


City, State, Zip