Medical Records Request Form

MEDICAL RECORDS REQUEST FORM

[ORGANIZATION NAME]
[ADDRESS]
[PHONE] | [FAX]
[EMAIL]

SECTION 1: PATIENT INFORMATION

Patient Name: [PATIENT FULL LEGAL NAME]

Date of Birth: [DATE OF BIRTH]

Social Security Number (last 4 digits): XXX-XX-[LAST 4]

Medical Record Number (if known): [MRN]

Address: [PATIENT ADDRESS]

City, State, ZIP: [CITY, STATE ZIP]

Phone Number: [PHONE]

Email Address: [EMAIL]

SECTION 2: REQUESTOR INFORMATION (if other than patient)

☐ I am the patient requesting my own records

☐ I am requesting records on behalf of the patient (complete below)

Requestor Name: [REQUESTOR NAME]

Relationship to Patient:
☐ Parent/Legal Guardian of Minor
☐ Legal Guardian/Conservator
☐ Healthcare Power of Attorney/Agent
☐ Personal Representative of Deceased Patient
☐ Attorney
☐ Other: [SPECIFY]

Address: [REQUESTOR ADDRESS]

Phone: [PHONE]

Email: [EMAIL]

Documentation of Authority Attached:
☐ Power of Attorney
☐ Court Order
☐ Letters Testamentary/Administration
☐ Other: [SPECIFY]

SECTION 3: RECORDS REQUESTED

3.1 Date Range

Records From: [START DATE] To: [END DATE]

☐ All records on file

3.2 Type of Records Requested

☐ Complete Medical Record (all available records)

☐ Specific Records Only (check all that apply):
☐ History and Physical Examination
☐ Progress Notes / Office Notes
☐ Consultation Reports
☐ Discharge Summary
☐ Operative/Procedure Reports
☐ Emergency Room Records
☐ Laboratory Results
☐ Pathology Reports
☐ Radiology/Imaging Reports
☐ Radiology/Imaging Films/CDs
☐ EKG/Cardiac Testing Reports
☐ Medication List / Prescription Records
☐ Immunization Records
☐ Allergy List
☐ Problem List
☐ Referral Letters
☐ Billing Records / Itemized Statement
☐ Insurance Claims Information
☐ Other: [SPECIFY]

3.3 Special Categories

☐ HIV/AIDS Information - I specifically request HIV/AIDS-related records

☐ Mental Health/Psychiatric Records - I specifically request mental health records

☐ Substance Use Disorder Treatment Records - I specifically request substance use disorder records (protected under 42 CFR Part 2)

☐ Genetic Testing Information - I specifically request genetic testing results

☐ Psychotherapy Notes - I specifically request psychotherapy notes (separate authorization may be required)

SECTION 4: PURPOSE OF REQUEST

☐ Personal/Family Records
☐ Continuing Care / New Provider
☐ Second Opinion
☐ Insurance/Benefits Claim
☐ Legal Matter
☐ Disability Determination
☐ Workers' Compensation
☐ Life Insurance Application
☐ Other: [SPECIFY]

SECTION 5: DELIVERY METHOD AND FORMAT

5.1 Delivery Method

☐ Pick up in person (Photo ID required)

☐ Mail to address listed in Section 1 or 2

☐ Mail to different address: [ADDRESS]

☐ Secure fax to: [FAX NUMBER]

☐ Secure email to: [EMAIL ADDRESS]

☐ Patient Portal (if available)

☐ Direct transmission to provider: [PROVIDER NAME AND CONTACT]

5.2 Format Requested

☐ Paper copies

☐ Electronic format:
☐ CD/DVD
☐ USB drive (patient-provided or facility-provided at additional cost)
☐ Secure email
☐ Patient portal
☐ Other electronic format: [SPECIFY]

☐ I have no preference

SECTION 6: FEES

I understand that a reasonable, cost-based fee may be charged for providing copies of my medical records. Current fee schedule:

Estimated Total: $[AMOUNT] (actual fees may vary based on records requested)

☐ I understand and agree to pay the applicable fees

☐ I am unable to pay and request fee waiver consideration

SECTION 7: TIMING

I understand that:

☐ Records will be provided within 30 days of receipt of this request

☐ If an extension is needed, I will be notified in writing within 30 days

☐ If records are maintained off-site, the response time may be extended by an additional 30 days

Urgent request: ☐ Yes ☐ No

If urgent, please explain: [REASON FOR URGENCY]

SECTION 8: PATIENT AUTHORIZATION AND SIGNATURE

By signing below, I hereby authorize [ORGANIZATION NAME] to release the medical records described above.

I understand that:

☐ I have the right to inspect my records before receiving copies

☐ I may revoke this request at any time in writing, but revocation will not affect records already released

☐ Information released pursuant to this authorization may be subject to re-disclosure

☐ I may be charged a reasonable, cost-based fee for copies

☐ I will receive a response within 30 days (or 60 days if extension notice provided)

☐ I may file a complaint with the organization or HHS if my request is not handled properly

Patient/Authorized Representative Signature: ______________________________________

Printed Name: [NAME]

Relationship to Patient (if applicable): [RELATIONSHIP]

Date: ______________

SECTION 9: VERIFICATION OF IDENTITY (For Office Use)

Identity Verified By: [STAFF NAME]

Method of Verification:
☐ Photo ID (type: [TYPE])
☐ Knowledge-based verification
☐ Signature comparison
☐ Other: [SPECIFY]

Date Verified: ______________

SECTION 10: FOR OFFICE USE ONLY

Date Request Received: [DATE]

Received By: [STAFF NAME]

Request Complete: ☐ Yes ☐ No - Missing: [ITEMS]

Date 30-Day Deadline: [DATE]

Extension Needed: ☐ Yes ☐ No

Extension Notice Sent: ☐ Yes ☐ No Date: [DATE]

Records Located: ☐ Yes ☐ No ☐ Partial

Records Reviewed By: [NAME] Date: [DATE]

Date Records Prepared: [DATE]

Fee Calculated: $[AMOUNT]

Fee Paid: ☐ Yes ☐ No ☐ Waived Date: [DATE]

Date Records Released: [DATE]

Method of Release: ☐ Mail ☐ Fax ☐ Email ☐ In-person ☐ Portal ☐ Other

Number of Pages/Files: [NUMBER]

Released By: [STAFF NAME]

Notes: [NOTES]

DENIAL OF ACCESS (if applicable)

☐ Access Denied

Reason for Denial:

Unreviewable Grounds (45 CFR § 164.524(a)(2)):
☐ Psychotherapy notes
☐ Information compiled for legal proceedings
☐ Certain research information (participant agreed to access restrictions)
☐ Information from non-healthcare provider under promise of confidentiality
☐ Records subject to CLIA that are not yet available

Reviewable Grounds (45 CFR § 164.524(a)(3)):
☐ Licensed healthcare professional determined access likely to endanger life or safety
☐ Information references another person, and access could cause substantial harm to that person
☐ Request made by personal representative, and access could cause substantial harm to individual

If denial is reviewable:
☐ Patient notified of right to have denial reviewed
☐ Designated reviewing official: [NAME/TITLE]
☐ Review completed - Decision: ☐ Upheld ☐ Reversed

Denial Notice Sent: ☐ Yes Date: [DATE]

COMPLAINTS

If you believe your rights have been violated, you may file a complaint with:

[ORGANIZATION NAME] Privacy Officer:
[NAME]
[ADDRESS]
[PHONE]
[EMAIL]

U.S. Department of Health and Human Services:
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
www.hhs.gov/ocr/privacy/hipaa/complaints