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Centers for Medicare & Medicaid Services

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Templates and Sample Request Letters

Templates and Sample Request Letters

  • Sample FOIA Request Letter (PDF)
  • Sample FOIA Request Letter for Your Own Medical Records (PDF)
  • Sample FOIA Request Letter for Records on a Living Beneficiary from Someone Other Than the Beneficiary (PDF)
  • Sample FOIA Request Letter for Records on a Deceased Beneficiary (PDF)
  • Sample FOIA Appeal Letter (PDF)
  • Medicare Authorization to Disclose Personal Health Information (PDF)
Page Last Modified:
12/01/2021 05:40 PM
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