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Medical Record Request Form Template

Streamline Your Medical Record Requests Effortlessly

Struggling to get your medical records transferred can be frustrating and time-consuming. Our medical record request form template simplifies the process for patients, making it easy to request your medical records from one healthcare provider to another. With this template, you gain a user-friendly solution to securely and effectively submit your requests, track progress, ensure compliance with privacy regulations, and improve communication with healthcare facilities. Start using the template today to streamline your record transfer process.

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Your full name
Your email
Your phone
Your relationship to the patient
Self (I am the patient)
Parent or legal guardian
Power of attorney or personal representative
Spouse or partner
Family member (authorized)
Attorney or legal representative
Other
Please Specify:
Patient full name
Patient date of birth
Patient city and state
Which records are you requesting?
Please Specify:
Date range start
Date range end
Additional details or specific documents requested
Purpose of request
Personal use
Continuity of care
Insurance
Legal
Employment
School or camp
Disability or benefits
Prefer not to say
Other
Please Specify:
Preferred delivery format
Secure electronic PDF via email/portal
Paper copies by mail
Fax
In-person pickup
Recipient name or organization
Delivery email (for electronic PDF or portal invite)
Mailing address for delivery (if requesting mail delivery)
Where should the records be sent?
To me (the requester)
To the patient
To another healthcare provider
To another person or organization
Facility or provider name
Facility city and state
I certify that I am authorized to request these records as described in this form.
Yes
No
I acknowledge that fees may apply and that processing times may vary per provider.
Yes
No
Authorization expiration date (if applicable)
Type your full name as your signature
Today's date
Exclude the following categories from release (if any)
Do not include mental health treatment notes
Do not include substance use treatment information
Do not include HIV/AIDS information
Do not include STI/sexual health information
Do not include genetic testing information
No exclusions
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Paper art illustration showcasing a medical record request form template for FormCreatorAI article

When to use this form

Use this form when you need copies of your chart for a new doctor, an insurance claim, or personal records. It helps patients, parents or guardians, and care coordinators get the right documents without delays. Examples: you are switching clinics and want progress notes, labs, and imaging; pair it with a Transfer of medical records form to move files directly. After discharge, confirm what you signed with the Hospital patient release form and then request your full visit summary. If you recently visited the ER, note details from the Emergency room admission form so staff can find the encounter fast. Clear requests reduce back-and-forth and help your provider send accurate, timely records.

Must Ask Medical Record Request Questions

  1. What specific records and date range do you need?

    Listing document types and time bounds prevents over- or under-sharing and speeds retrieval. It helps staff query the EHR by visit, department, or test and deliver only what you expect.

  2. Who is the patient authorizing this request? (full name and date of birth)

    Identity details match the record and protect privacy. They also avoid mix-ups when patients share similar names.

  3. Where should we send the records and in what format?

    The destination and format (portal, secure email, fax, mail, PDF, paper, CD) determine the delivery steps and timeline. Confirming this up front reduces resends and protects confidentiality.

  4. What is the purpose of your request?

    Purpose guides urgency and scope (continuity of care, personal use, insurance, legal). If it relates to COVID-19 status, include details from the COVID 19 positive diagnosis form so staff can locate the right encounter.

  5. Are you the patient? If not, what is your relationship and do you have signed authorization?

    Role and authorization show legal permission to access the chart, such as parent, caregiver, or attorney. It helps the team verify consent before releasing records.

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