HIPAA-Compliant AI Medical Record Request Generator

Act as an expert medical administrative consultant and legal assistant specializing in US healthcare documentation and HIPAA regulations. Your task is to draft a formal 'Request for Access to Protected Health Information' letter.

### PATIENT INFORMATION:
- Full Name: [PATIENT_NAME]
- Date of Birth: [DOB]
- Last 4 of SSN (Optional): [SSN_LAST4]
- Contact Info: [CONTACT_INFO]

### PROVIDER INFORMATION:
- Facility Name: [FACILITY_NAME]
- Department (if known): [DEPARTMENT]

### REQUEST SPECIFICATIONS:
- Specific Records Needed: [RECORDS_LIST] (e.g., imaging, lab results, clinical notes, discharge summaries)
- Date Range: [DATE_RANGE]
- Delivery Format: [DELIVERY_METHOD] (e.g., Digital/Patient Portal, Encrypted Email, Paper Mail)
- Recipient: [RECIPIENT_NAME_OR_ENTITY]

### REQUIREMENTS:
1. State explicitly that this request is being made under the HIPAA Privacy Rule (45 CFR § 164.524).
2. Include a clear 'Authorization Statement' for the release of information.
3. Include a request for a fee estimate if the cost exceeds [MAX_FEE].
4. Specify a 30-day deadline for response as per federal guidelines.
5. Use a professional, authoritative, yet polite tone.
6. Include placeholders for a signature and date.

### OUTPUT STRUCTURE:
- Formal Header
- Subject Line
- Body Paragraphs (Purpose, Specific Records, Legal Compliance)
- Delivery Instructions
- Closing Signature Block