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Transfer of Medical Records Form Template

Effortlessly manage your medical records transfer with our user-friendly template

Struggling to get your medical records transferred can delay your healthcare. This Transfer of Medical Records Form Template supports patients and healthcare providers in efficiently requesting and authorizing the transfer of important medical data. Enjoy quick processing, enhanced organization, and improved communication between providers, while ensuring compliance with regulations. Plus, our WCAG-aligned labels ensure accessibility for all users. Explore the live template and simplify your medical records transfer.

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Patient full name
Date of birth
Patient phone number
Patient email address
Patient mailing address
Medical record number (if known)
Are you the patient?
Yes
No
From provider or clinic name
From provider phone
From provider fax
From provider email
From provider address
Recipient name or organization
Recipient attention or contact person
Recipient phone
Recipient fax
Recipient email
Recipient address
Purpose of disclosure
Please Specify:
Record types requested
If other record types, specify
Record date range selection
All dates
Most recent 12 months
Specific date range (enter below)
Start date (if specifying a date range)
End date (if specifying a date range)
Preferred file format
PDF
Paper copies
Consolidated summary (where available)
FHIR/CCD or other structured format
CD/DVD
USB drive
Other
Please Specify:
Preferred delivery method
Secure email
Fax
Mail
Pickup in person
Electronic portal access
Courier
Other
Please Specify:
I understand that email or fax may involve privacy risks and consent to proceed if selected
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Do you want to include any sensitive categories?
Yes
No
If other sensitive category, specify
Authorize release of the following sensitive categories (select all that apply)
HIV/AIDS information
Sexually transmitted infection information
Behavioral or mental health information
Substance use treatment information
Genetic testing information
Reproductive health information
Other sensitive information (specify below)
Authorization expiration
Expires 90 days from signature
Expires one year from signature
Expires on the specific date provided below
No expiration where permitted by law
Specific expiration date (if applicable)
I understand I may revoke this authorization in writing at any time, except to the extent action has already been taken
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand that information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand that signing this authorization is voluntary and treatment, payment, or eligibility is not conditioned on signing
Strongly disagree
Disagree
Neither
Agree
Strongly agree
The information provided in this form is accurate to the best of my knowledge
True
False
Are you signing as a legal representative of the patient?
Yes
No
Representative full name
If other relationship, specify
Description of authority or documentation (e.g., POA, guardianship)
Representative phone
Representative email
Relationship to patient
Self
Parent
Legal guardian
Healthcare power of attorney
Spouse or partner
Adult child
Other
Please Specify:
Name of person authorizing the release
Signature
Date signed
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
paper art illustration depicting a transfer of medical records form for medical documentation and organization

When to use this form

Use this form when you change doctors, move to a new clinic, or see a specialist who needs your history, labs, and imaging. It also helps when a caregiver manages a child's or parent's care and needs records sent to multiple providers. Submit it after a hospital stay so your follow-up team sees discharge notes, medications, and restrictions. For context, you may reference details from your Hospital discharge form and your Discharge instructions form. With a clear request, you reduce delays, avoid duplicate tests, and give your next provider the full picture.

Must Ask Transfer of Medical Records Questions

  1. Who should receive your records, and how can we contact them?

    Full name, department, address, phone, and secure fax or email ensure delivery without back-and-forth. Accurate details cut turnaround time and prevent misrouted files.

  2. Which records and date range do you want sent?

    Naming types (visit notes, labs, imaging) and a date span keeps the transfer focused and faster. It also limits sharing to what your new provider truly needs.

  3. Do you authorize release of your information for this purpose?

    An explicit consent with your signature and date is often required before providers send records. If your organization uses a separate authorization, attach the Medical record release form.

  4. How should we deliver the records?

    Your preference (secure portal, health information exchange, encrypted email, fax, or mail) affects speed, cost, and file format. Choosing a secure method protects privacy and avoids rework.

  5. Is there a deadline or upcoming appointment we should prioritize?

    A target date or appointment time helps staff triage urgent requests. It also sets expectations for follow-up if the deadline is at risk.

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