The Hospital Manager,
__________ (Hospital Name),
__________ (Address)

Date: __/__/____ (Date)

Subject: Request for issuance of medical record

Respected Sir/ Madam,

I am __________ (Name) and I am a resident of __________ (Address). I would like to state that I got admitted/ treatment for ________ (Mention) on __/__/____ (Date).

I am writing this letter to request you for issuance of __________ (Inform what record you want). As per hospital guidelines, I request you to issue a copy of my medical records.I need this for ________ (Reason). My patient ID is __________ (Patient ID).

I am ready to pay all charges applicable. For any queries, you may contact me at ________ (Contact number). I expect to hear back from you at the earliest.

Thanking You,
__________ (Signature),
__________ (Name),
__________ (Contact Number)

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