[Your Name]

[Street Address]

[City, ST ZIP Code]

[Date]

[Doctor Name]

[Medical Practice or Hospital Name]

[Street Address]

[City, ST ZIP Code

RE:	Release of medical records for [Your Name]
DOB: [date], SSN: [Social Security Number]

Dear [Doctor Name]:

On [date], I sent you a written request asking for copies of my medical records related to treatment for [medical conditions] rendered by you or under your supervision from [date] through [date]. Since then, [number] days have passed and I have not yet received these records.

I am hereby making a second request that you send me these records immediately. I remind you that under the laws of this state, Statute #[number], you are legally obligated to provide copies of my medical records upon my request.

If I have not received the records by [date], I will have no choice but to retain an attorney to obtain my medical records for me. By law, you will then be liable for the attorney fees that I incur. I trust that this step will not be necessary.

Please mail the information to:

[Your Name or Name of Party to Receive Records]

[Street Address]

[City, ST ZIP Code]

As noted in my first request, I will be glad to pay for costs associated with providing me copies of my records.

Sincerely,

[Your Name]