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ITRC Letter Form 130A

ITRC Letter Form 130A – Request for Medical Records, is for use by victims of medical identity theft.  This sample letter uses language that may be useful in making a case for removing incorrect information from a health provider’s record:

For additional information, please refer to ITRC Fact Sheet FS 130 –  Correcting Misinformation on Medical Records

Click to download the form:

LF 130a Form

This letter form should not be used in lieu of legal advice. Any requests to reproduce this material, other than by individual victims for their own use, should be directed to itrc@idtheftcenter.org. ITRC thanks the CRA’s in providing material for this guide.

Copyright, Identity Theft Resource Center®, all rights reserved. Created by ITRC