MEDICAL RECORDS REQUEST FORM SAMPLE

How to request your medical records from your health care provider through a medical records request form.

HOW TO ACCESS MEDICAL RECORDS. 

In order to get a hold on your medical/health information check your health care provider’s website online patient portal where you can do things such as; contact the provider, look at lab results, see a list of the immunizations you’ve had, and make appointments. 

How to check medical records. Get medical records online.

If the health information you are looking for is not available through the patient portal, try  contacting your provider though the Contact Us section on their website, make a phone call request, an email request, or send them a medical records request form.

How to fill out a health or medical record release form. (You can request the health records for only 1 person per form.)

  • Patient information. Print full name, date of birth, medical record number (MRN), or patient identification number (PIN). 
  • Organization Information. Full name, address, phone number, and fax or email address of doctors, hospital, clinic, or care provider. 
  • Information to be released. Check all boxes that apply.
  • Date of Services. You can request records from one day to a range of dates or years.
  • Purpose of release. According to HIPAA, you don’t have to write this information to get your health records. Leave this section blank if you desire.
  • Receiving party or destination of records. Provide the full name of the person, place, or company, along with their address, telephone number, and fax number or secure email (through their patient portal). Note: a separate request may be required, if you need to send your it to more than 1 person, including yourself.
  • Expiration date or duration of consent. Most permissions will end in SIX months to ONE year from the date on the form. But you can specify the date, if you desire. Note: your health care provider can take up to 30 days to deliver your health records.
  • Signature of patient or representative.
  • Date of request. Enter the date after signing the authorization form.
  • Release instructions. Disclose the date and the kind of record you want, like a PDF, or regular paper.
  • Relation to the patient. If you’re not the patient, tell the provider how you are related to the patient and that you are the patient’s personal representative.
  • Legal. You must provide a copy of the legal paperwork giving you the right to access any adult’s health information, other than your children.

If you did not received your records after 30 days. Try searching your provider’s website for the Customer or Patient Care information, often found in the Contact Us section. 

Patient privacy and rights: The HIPAA privacy officer make sure your provider is following the rules for protecting your rights and the privacy of your health record and your right to access it. The Privacy or Contact Us section of your provider’s website should disclose HIPAA information.

Why are medical records important?

Medical record keeping is essential to hospitals and clinics and to the care of patients by empowering doctors and healthcare professionals to treat patients by practicing medical care the best way possible.

MEDICAL RECORDS REQUEST FORM SAMPLE

Information regarding patient for whom authorization is made:

Full Name: _______________________________________________________

Other Name(s) Used: ____________________________________ Date of Birth: _________________________

Address:____________________________________________________

City:___________________________ State: ______ Zip Code: ________

Phone: (_____) ___________________ Email (Optional): ____________________

I HEREBY AUTHORIZE THE FOLLOWING HEALTH CARE ENTITIES, THEIR PROVIDERS, NURSES, AND OTHER PERSONNEL TO DISCUSS MY DESIGNATED HEALTH INFORMATION, IN PERSON OR BY TELEPHONE, WITH ALL OR ANY OF THE INDIVIDUALS INVOLVED IN MY CARE AND IDENTIFIED BELOW:

Information regarding health care provider or health care entity authorized to disclose this information:

Name: ________________________________________________

Address:____________________________________________________

City:___________________________ State: ______ Zip Code: ________

Phone: (_____) ___________________ Fax: (_____) _______________________

Information regarding person or entity who can receive and use this information:

Name: ______________________________________________________

Address:____________________________________________________

City:___________________________ State: ______ Zip Code: ________

Phone: (_____) ___________________ Fax: (_____) _______________________

Specific information to be  disclosed:

□ Medical Record from (insert date) ___________________ to (insert date) ___________________

□ Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records received from other health care providers.

□ Other: __________________________________________________________________

Include: (Indicate by Initialing)

______ Drug, Alcohol or Substance Abuse Records

______ Mental Health Records (Except Psychotherapy Notes)

______ HIV/AIDS-Related Information (Including HIV/AIDS Test Results)

______ Genetic Information (Including Genetic Test Results)

Reason for release of information: (Choose all that Apply)

______ Treatment/Continuing Medical Care

______ Personal Use

______ Billing or Claims

______Insurance

______Legal Purposes

______Disability Determination

______School

______Employment

______Other (Specify): ___________________

Individuals Involved in My Care:

_______________________   _______________________   ____________________

Full Name                                 Relationship                             Phone Number

_______________________   _______________________   ____________________

Full Name                                 Relationship                             Phone Number

_______________________   _______________________   ____________________

Full Name                                 Relationship                             Phone Number

I understand that the information Individuals Involved in My Care receive may be redisclosed and no longer protected by federal or state privacy regulations. I also understand that my Designated Health Information may contain information related to treatment for drug and/or alcohol abuse treatment, psychotherapy treatment, or HIV and/or AIDS related diagnosis and treatment. If applicable, by checking those respective boxes above, I acknowledge and expressly permit the inclusion of such information in verbal communications permitted

by this authorization. I understand that this authorization is voluntary and that I may refuse to sign it. My refusal to sign will not affect my ability to obtain treatment. If, at any time, I do not want my Health Care Providers to have verbal discussions with myself or any of the

Individuals Involved in My Care, I must notify my Health Care Provider in writing. No Health Care Provider will be liable for communications that were permitted by this authorization and made prior to its revocation.

SIGNATURES:

Patient/Legal Representative: ___________________________ Date: _______________

If Legal Representative, relationship to Patient:  _______________________________

Witness (optional): ___________________________________  Date: ______________

A minor individual's signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment.

Signature of Minor (if applicable):___________________________ Date: ___________


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