Date: ____________________
To:
RE: Patient _____________________________
Service Dates _____________________________
After careful consideration:
I hereby request a printed copy of all my medical and/or dental records in your custody or possession for my account and service date as referenced above. Please include any lab test results and all data collected for the dates above. I need printed copies, because electronic records and records on an electronic network portal are not helpful.
This request is made pursuant to HIPAA Privacy Rules (as defined in 45 C.F.R. �160.103 under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA Rules")) and Florida Statutes FS 32 456.057.
Please send these records to me at the mailing address below, and advise me first if there are any copying fees or other charges greater than fifty dollars ($50.00).
Please communicate with me by phone or USPS mail if necessary, contact information is below.
Sincerely yours,
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