Clinic

Primary Care / Family Medicine

Annual visit notes, preventive care, chronic condition records

Common uses

•Specialist referrals
•Insurance enrollment
•School / work requirements

How to find the fax number

Ask your primary care office for their medical records or HIM fax number. Many practices list it on their patient portal.

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Request Records — Primary Care / Family Medicine

Select a template, complete the patient information fields, enter the provider fax number, and send.

Choose a template

Subject: Request for Release of Medical Records — [PATIENT_NAME]

Authorization text

Replace all [BRACKETS] before sending

Authorization for Release of Health Information (HIPAA Compliant)

To the Medical Records / Health Information Management Department,

PATIENT INFORMATION
Patient Full Name: [PATIENT_NAME]
Date of Birth: [DATE_OF_BIRTH]
Last 4 SSN (optional): [SSN_LAST_4]
Address on file: [PATIENT_ADDRESS]
Phone: [PATIENT_PHONE]

RECORDS REQUESTED
Dates of Service: [DATE_RANGE — e.g., 01/01/2023 to 12/31/2024]
Type of Records: [RECORD_TYPES — e.g., complete medical record, office visit notes, lab results, imaging reports, operative reports, discharge summaries]
Specific Provider / Department: [PROVIDER_OR_DEPT — if applicable]

PURPOSE OF REQUEST
[PURPOSE — e.g., Continuity of care with new provider, insurance claim, disability application, personal records, legal proceeding]

RELEASE TO (send records to)
Name / Organization: [RECIPIENT_NAME]
Fax: [RECIPIENT_FAX]
Address: [RECIPIENT_ADDRESS]

AUTHORIZATION
I understand that I have the right to revoke this authorization in writing at any time except to the extent that action has already been taken. This authorization will expire: [EXPIRATION — e.g., 90 days from today, or upon completion of the request].

I understand that the records released may include information about mental health, substance use, HIV/AIDS, or other sensitive conditions, and I specifically authorize their release.

Signature: ____________________________
Printed Name: [PATIENT_NAME]
Date: [TODAY_DATE]
Relationship to Patient: [SELF / Guardian / Legal Representative]

Please send records to the fax number shown above. If you require an original signature or specific form, please fax your requirements to [YOUR_FAX_NUMBER]. Under HIPAA, you must respond to valid record requests within 30 days.

Thank you for your prompt assistance.

⚠️ 17 unfilled fields remaining: [PATIENT_NAME], [DATE_OF_BIRTH], [SSN_LAST_4]…

Provider fax number *

Ask your primary care office for their medical records or HIM fax number. Many practices list it on their patient portal.

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Formatted as a records release authorization letter and faxed directly. 1 credit per fax. Sign up free →