Date: ___________________


               RE:       Medical Record and Itemized Billing Statement Request

To Whom it May Concern,

I am requesting that a copy of my medical records, including billing statements, be given or mailed to me at _____________________________________________________________ under the HIPAA privacy rule.  Enclosed is a HIPAA compliant authorization.

Pursuant to 45 CFR 164.524[c][2][ii], I request access to the records in electronic format. I request that you either advise me when I may appear at your facility and copy the electronic records, or in the alternative, ask that you provide the records in electronic format via email to _________________________, or by mailing appropriate media through the U.S. mail service or similar service.

Pursuant to federal regulation, I will direct that payment of $6.50 be made upon receipt of the electronic copy.  If the charge for records in electronic format exceeds the amount specified by that federal regulation, forward the itemized cost based fee to be charged at your earliest possible moment to me.

Federal law specifically disallows the charges authorized under Missouri law for the producing of medical records, 45 CFR 164.524[c][4]. If the facility does not maintain the records in electronic format, please itemize the fee for providing records by returning and accounting of the labor for copying the medical records, supplies, and mailing costs.

HIPAA requires that these records be forwarded in 30 days or less.  If you are unable to provide the records within this time period, please inform me in writing of the reason for delay and date by which the records will be provided.