Medical Records Request Invoice Template

The medical records invoice is sent to bill a patient for the request and transfer of their health care history. In accordance with § 45 CFR 164.524(c)(4), a medical office may charge a patient for the labor, supplies, postage, and preparing a summary or explanation of the protected health information. However, each State places a limit on how much a medical office may charge for this request (See Maximum Amounts). The records will be delivered to the requesting patient once they have paid the full amount written on the medical records invoice.

How to Write in PDF or Word

Step 1 – Download in Adobe PDF or Microsoft Word (.docx).

Step 2

How to Write in Excel

Step 1 – Download in Microsoft Excel (.xlsx)

Step 2