Sample Advocacy Letters

Jonathan's Law - Access to Clinical Records Sample

Your address
Your phone number

Date

Records Manager
Provider Name (agency providing services)
Address

RE: Request for Access to Records of Name of person receiving services:(his or her date of birth) Pursuant to Article 33 of the Mental Hygiene Law

Dear Records Manager:

I would like to review all clinical records, incident reports, and reports on actions taken, if any, pertaining to name of person receiving services from the date he/she began receiving services from your agency in month/year through the date of this request. Please contact me at the phone number or address above and advise me of specific dates and times when I can have access to said records. I may wish to copy some or all of the records, so please ensure that a means of copying is available. I understand that I will be charged a reasonable fee for copies, not to exceed $0.75 per page.

[or]

Please provide me copies of the clinical records, incident reports, and reports on actions taken, if any, pertaining to name of person receiving services from the date he/she began receiving services from your agency in month/year through the date of this request. I understand that I will be charged a reasonable fee for copies, not to exceed $0.75 per page. However, if the fee for copying said records and reports will exceed $XX.00, please contact me before any copies are made.

I am a "qualified person" to receive access to these records because I am the ([choose one]parent, legal guardian, spouse, adult daughter, adult son) of name of person receiving services, and I have the authority to provide consent for his/her care and treatment pursuant to the enclosed (choose one:)
If person is under 18 and you are parent, copy of his or her birth certificate or adoption papers identifying you as parent
If person is under 18 and you are legal guardian, copy of court order naming you legal guardian
If person is 18 or older, copy of court order naming you legal guardian
If person's spouse, copy of marriage certificate
If person's adult child, copy of your birth certificate and copy of court order giving you legal authority to make health care decisions for the person
[or]
the individual receiving services.

Thank you for your attention to this matter. I look forward to hearing from you within ten (10) business days.

Sincerely,

Signature
Printed name

Enc.

Sample Letter

222 Western Avenue
Nowhere, NY 00000
(000)-000-0000

March 1, 2008

Records Manager
ACME Care Services
0000 Main Street
Anywhere, NY 00001

RE: Request for Access to Records John R. Doe (DOB: 12/31/95) Pursuant to Article 33 of the Mental Hygiene Law

Dear Records Manager:

I would like to review all clinical records, incident reports, and reports on actions taken, if any, pertaining to John R Doe from the date John began receiving services from your agency in June 2004 through the date of this request. Please contact me at the phone number or address above and advise me of specific dates and times when I can have access to said records. I may wish to copy some or all of the records, so please ensure that a means of copying is available. I understand that I will be charged a reasonable fee for copies, not to exceed $0.75 per page.

I am a "qualified person" to receive access to these records because I am John's legal guardian, and I have the authority to provide consent for his care and treatment pursuant to the enclosed Order of the Surrogate's Court of Nowhere County.

Thank you for your attention to this matter. I look forward to hearing from you within ten (10) business days.

Sincerely,

Signature
Jane Smith

Enc.

Special Note:

Prior to using the above sample letter, please read the helpful information at the following link:

http://www.cqcapd.http://www.cqcapd.state.ny.us/Brochures/Access-to-MH-Records.htm

Sample Letter Provided by Family Resource Network, Inc.