Records Request Letter Template

Via [Certified Mail/Email/Fax]
Date: [Date]

To: [Custodian of Records]
[Institution/Agency]
[Address]

Re: Request for Records – [Client Name / Matter Reference]

Dear Custodian,

1. Identification of Requestor

I represent [Client Name], whose date of birth is [DOB] and whose relevant identifiers include [e.g., last four digits of SSN, patient ID, account number]. I am authorized to request the records described below. Enclosed is a signed authorization compliant with [HIPAA/State Privacy Law] and a copy of identification if required.

2. Records Requested

Please provide true and complete copies of the following records for the period [Date Range]:
- Medical records, charts, physician notes, nursing notes, operative reports, diagnostic images, laboratory results, billing ledgers, and insurance correspondence related to [facility/visit].
- Employment records, including personnel file, payroll records, time sheets, disciplinary actions, performance evaluations, and benefits information.
- Educational records, including transcripts, disciplinary reports, Individualized Education Programs (IEPs), 504 plans, and correspondence with [school/department].
- Incident reports, security logs, video footage, photographs, and witness statements concerning [event/date/location].
- Any additional documents referencing [keywords/subject].

(Modify categories to match request.)

3. Format and Delivery

• Produce records electronically (PDF, TIFF with load files, or native format) via secure portal, encrypted email, or USB drive. If paper copies are necessary, please notify us of copying charges before fulfillment.
• Include an itemized invoice showing copying, certification, and administrative fees; remit payment instructions.
• For digital media, ensure files are clearly labeled and indexed by date and document type.

4. Deadlines and Contact Information

Please respond within [Number] days as required by [applicable statute or regulation]. If you anticipate delays, contact us immediately with an estimated completion date.

Direct all communications to:

[Attorney/Records Specialist Name]
[Law Firm/Organization]
[Address]
[Phone] | [Email]

5. Certification

If possible, provide a certification or affidavit of records custodian authenticity suitable for court use. Enclosed is a proposed certification form for your convenience.

6. Costs and Payment

We agree to pay reasonable reproduction fees permitted by law. Please advise if prepayment is required. Checks should be payable to [Entity Name]; provide mailing or online payment instructions.

Thank you for your prompt attention. Please contact us with any questions or to confirm receipt of this request.

Sincerely,

[Attorney/Requestor Name]
[Title]
[Law Firm/Organization]

Enclosures: Authorization, Custodian Certification Form, Identification Copy (if required)