200 Baltimore St.
100 Broadway Lane
March 30, 2019
Seasame Spine and Pain Institute
123 Main Street, Suite 100
St. Charles, CA 60174
Subject: requesting a copy of my medical records
I am writing you to request the copy of my medical records. I was treated in your office on March 12, 2019. Please include all of my charts, test results, and consultation notes including referrals regarding my medical care.
I understand I may be charged a fee for copying my medical records, however, I will not be charged for any time that is spent locating my records.
Please mail the requested information to me at the address listed above. I have enclosed a self-addressed envelope for your convenience. I understand that I will be charged for postage.