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(Sender Name) (Sender Title/Position) (Sender Organization Name) (Sender Street Address) (City, State, Zip Code)

(Recipient Name) (Recipient Title/Position) (Organization Name) (Recipient Street Address) (City, State, Zipcode) RE: (Medical Identification Number) To Whom It May Concern:

(Date)

The purpose of this letter is to request copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations. I was treated in your office between (date from) to (date to). I would like to request copies of the all the health records related to my treatment. Appreciate if you can mail the request to my billing address as registered under my Medical Identification Number. Please contact me at xxx-xxxx-xxxx-xx if you need any further clarification for my request. Thanks in advance.

Sincerely, (Name) (Position Title)

I am writing on behalf of my brother, Gregorio M. Tiqui.