The Manager – Medical Record Department (MRD),
___________ Hospital (Hospital Name),
___________ (Address)

Subject: Application for Issuance of Medical Record of Patient _______ (Patient Name), Patient ID – ________

Respected Sir/Madam,

This is to inform you that I ________ (Patient Name) got admitted in your hospital on _______ (dated) having patient ID ________ (Patient ID).

I am writing this letter in order to request you to issue medical records pertaining to his hospitalization as I have to _______ (the reason for issuance of medical records – medi claim insurance/ personal reasons/ any other reason).

All the dues related to his/her hospitalization have already been paid. The copy of the payment is enclosed for your reference.

I request you to kindly issue the medical records at the earliest.

Yours truly,
_______ (Signature)
_______ (Your Name)
_______ (Contact Number)


• Copy of Bill
• ID/Address Proof (If applicable)
• _______ (Any Other Supporting Document – if applicable)

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