Letter Form 130a - Request To Receive And/or Correct Medical Records

Letter Form 130a - Request To Receive And/or Correct Medical Records - Itrc

Request to Receive and/or Correct Medical Records

Date: _______________ Mailed certified, return receipt - Number: ________________

To (Agency Name) _______________________________________________________

Address/City/State/Zip ___________________________________________________

Health Insurance Number___________________

From: _________________________________________________________________

Address/City/State/Zip: ___________________________________________________

Phone Number___________________________ cell number ______________________

Email ___________________________________

I may be a victim of medical identity theft because _____________________________

______________________________________________________________________

The medical records your agency maintains about me may include information about someone

else. This information, if not corrected, may adversely affect my personal health care and/or

deny me insurance benefits.

I am requesting the following:

•

A copy of my medical records so that I can review them for information that may not

pertain to me.

•

In the event that you cannot send the records to me, I would like to set a date to come in

and review the records in your local office.

•

•Once I review the records, to have a “statement of disagreement” placed in a conspicuous

location on my medical records. It will serve as an alert for other health providers of the

medical identity theft issue and to verify my medical information prior to making a diagnosis

or prescribing medication.

•

That you notify any other entity that you have shared my records with of the corrections.

•

A letter from your agency confirming that the corrections have been made.

Your agency may have received fraudulent information from an identity thief. It is apparent

that we both have a vested interest in identifying misinformation and resolving this situation.

Should you have any questions regarding my request, please contact me at the phone

number/s above.

_________________________________

_______________________________

Signature

Date

Addendum:

List items of inaccurate information, including dates when possible.

ITRC Letter Form 130A

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Letter Form 130a - Request To Receive And/or Correct Medical Records - Itrc