I am requesting copies of my health information under 45 C.F.R. § 164.524: [all visit notes, results, imaging reports and images, operative and pathology reports, and billing records from (date) to (date)]. Please provide them in [electronic format / through the portal / on a disc], within thirty days. If there is a fee, please tell me the amount before preparing the copies. [Name, date of birth, address, phone.]
