HIPAA Right of Access Request Generator

Generate a printable HIPAA Right of Access request letter that a patient can send to a covered entity to obtain a copy of their own medical record.

Open the generator → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.

Example

Patient name: Jane Doe
Date of birth: 1985-03-12
Provider / facility name: Acme Internal Medicine
Date range requested: 2024-01-01 to 2025-01-01
Specific records requested: Office visit notes, lab results, imaging reports
Format requested: electronic (PDF)
Delivery address: patient portal

Result: Click "Build printable request" to render a 45 CFR 164.524 letter citing the 30-day response requirement and the cost-based fee cap.

The tool opens with these values already filled in. Replace them with your own.

What you enter

Patient name and date of birth; the provider or facility; the date range and records requested; and the format and delivery address.

What this is

The HIPAA Privacy Rule at 45 CFR 164.524 gives every individual the right to inspect and copy their designated record set, with a 30-day response deadline (extendable by one additional 30 days with written notice), a cost-based fee cap, and the right to designate a format and a delivery destination. Sophie Well fills the patient's name, the covered entity, the record range, and the requested delivery format into a complete letter ready to print and sign.

When to use it

Use this when you need a paper trail that triggers the 30-day clock under federal law, when a provider has been informally ignoring verbal record requests, or when a patient needs records sent directly to a third party (a new provider, an attorney, a research project) under the third-party-designation right. The generated letter cites 45 CFR 164.524, names the deadline explicitly, and frames the fee limit so the receiving release-of-information office cannot quote per-page rates above the cost-based cap. This is reference assistance, not legal advice; for an enforcement complaint, the patient files with the HHS Office for Civil Rights.

How this is calculated

HIPAA Privacy Rule, 45 CFR 164.524. Right of Access; 30-day response requirement with one 30-day extension; cost-based fee cap.

A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.