Please Sign Naturally

Request Letter
under HITECH Act of 2009 for Electronic Copy of my Medical Records





to 45 CFR § 164.524, I am requesting that you send an
electronic copy, in PDF format, of all of my protected health
information (“PHI”) from                             to                             to
my third-party designee, Schmidt National Law Group. I do not want a
PHI summary but the full set of records.

scan and/or convert electronic records to PDF format and email them to:

you are unable to email my PHI, you may fax them to: 619-393-1777

National Law Group should receive any and all correspondence, including
invoices for the reasonable cost-based fee for the labor cost of
copying my protected health information, paper or electronic media
supply costs, and postage costs. The applicable regulations provide the
following rules for compliance with this request:

  1. There is a 30-day deadline to supply the requested PH
  2. There is no requirement under the HITECH Act for a HIPAA
    authorization. This letter is suf
  3. There is no expiration event or date relating to this
    patient or the purpose of the use or disclosure of this information.
  4. Prohibited charges include access charges, inventory
    charges, labor for reviewing the request, searching for or retrieving
    the PH
  5. Medical records contractors are covered by HIPAA regulation
  6. Noncompliance includes charging more for sending the
    records to my third-party designee, Schmidt National Law Group, or any
    subsequent or additional third-party designe
  7. Noncompliance includes claiming the inability to provide
    the PHI via email or
  8. I have the right to revoke this authorization in writing.
  9. You may not condition treatment, payment, enrollment, or
    eligibility for benefits on whether I sign this authorization when the
    prohibition on conditioning of authorizations in (b)(4) of 45 CFR
    164.508 applies.
  10. There is a potential for information disclosed pursuant to
    this authorization to be subject to redisclosure by

National Law Group and will no longer be protected by this 45 CFR

copy is as valid as the original. Thank you for your prompt response.

Date (Signature is valid for 365 days)


more information on the Federal HITECH Act and its regulations: