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Medical Record Certification Form Template

Streamline accurate medical record verification with ease

Are you struggling to verify the authenticity of medical records? This Medical Record Certification Form Template is designed specifically for healthcare professionals who need to certify the accuracy and legitimacy of medical records. By using this template, you can ensure compliance, speed up administrative processes, and maintain a high standard of patient documentation, all while keeping your forms accessible with WCAG-aligned labels. Experience the ease of customizing fields to suit your specific needs-try the live template now.

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Patient full name
Date of birth
Patient ID or MRN
Patient address
Patient phone number
Patient email address
Last 4 digits of SSN (optional)
Requestor type
Patient
Legal representative
Attorney
Insurer
Healthcare provider
Employer
School
Other
Please Specify:
Requestor full name
Organization (if applicable)
Relationship to patient
Self
Parent/guardian
Spouse/partner
Attorney
Insurer
Provider
Employer
School
Other
Please Specify:
Request reference or claim number
Request date
Preferred delivery method(s)
In-person pickup
Mail
Fax
Secure email
Patient portal
Electronic data exchange
Other
Please Specify:
Delivery details for recipient (address, email, or fax)
Authorization date (if applicable)
Authorization to disclose is on file for this request
Yes
No
Records date range start
Records date range end
Types of records included
Please Specify:
Care settings included
Inpatient
Outpatient clinic
Emergency department
Telehealth
Home health
Other
Please Specify:
If exclusions apply, describe them
Are any records excluded from this certification
Yes
No
Facility or practice name
Department (if applicable)
Facility address
Facility phone
Facility email
Custodian of records full name
Custodian title or role
I certify the records described are true, complete, and accurate copies of the originals maintained by this organization
Yes
No
The records were made at or near the time of the events by persons with knowledge and kept in the regular course of business
Yes
No
I am authorized to make this certification on behalf of the organization
Yes
No
Number of pages or files certified
Additional remarks (optional)
Method of record reproduction
Electronic PDF
Printed hard copy
Scanned images
Electronic extract (CCD/HL7)
Other
Please Specify:
Place of certification (city, state)
Certification date
Signature of custodian of records
Printed name of signer
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient ID or MRN","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration related to medical record certification form template and FormCreatorAI

When to use this form

Use this form when you must attest that copies of a patient record are true, complete, and created in the regular course of care. It helps health information management (HIM) teams, clinics, and hospitals respond to attorney or insurer requests, court orders, and compliance reviews. If you still need to collect the chart before certifying it, start with the Medical record request form. Quality or compliance staff can pair this with the Medical record audit form during internal reviews. Typical cases include litigation packages, claim appeals, or releasing a certified discharge summary to a third party.

Must Ask Medical Record Certification Questions

  1. What is the patient's full name, date of birth, and medical record number (MRN)?

    These identifiers ensure you certify the correct chart and avoid mixing records for patients with similar names. They also let recipients match the certificate to their case or claim.

  2. Which record types and exact date range are you certifying?

    Scoping the content prevents oversharing PHI and keeps the package focused on what the recipient needs. It also reduces rework if only certain notes, labs, or images are required.

  3. Which facility or department created the records, and who was the treating provider?

    Source details help recipients verify authenticity and chain of custody. Some courts and insurers require the facility of origin to be named on the certificate.

  4. What is the reason for certification and the legal authority to receive these records?

    Stating the purpose supports HIPAA compliance and may determine whether notarization or specific wording is needed. If the need is to order tests rather than release records, use the Medical requisition form instead.

  5. Who is the custodian of records, and will you include signature, title, contact info, date, and any notarization?

    Clear custodian details make the certificate valid and easy to verify. Noting notarization needs up front prevents delays and rejected submissions.

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