Your Name

[Address]
[Address 2]
City, State Zip

[Date]

[Recipient name]
[Address]
[City, State Zip code]

Attn: Medical Records Department

RE:
Client: [Name(s)]
Date of Loss:

To whom it may concern:

Please be advised that the Law Offices of Attorney have been retained to represent
the above captioned client

We would like to request the itemized medical records for [Client] for date(s) of
service

Please forward all correspondence to [include persons name title phone number
and email address if applicable].

Truly,

[Name]
[Title]
[Phone number]