Medical Records Request Form Template

[Your Full Name]
[Street Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Email: [Email Address]
Date of Birth: [MM/DD/YYYY]
Last 4 digits of ID or Patient Number (if any): [___]

1. Patient Information

Patient Full Name (if different from above): [First, Middle, Last]
Other Names Used (maiden, prior names): [Names or “None”]

Date of Birth: [MM/DD/YYYY]
Phone Number: [Phone Number]
Email Address: [Email Address]

2. Healthcare Provider / Facility Holding the Records

Name of Provider / Facility: [Clinic / Hospital / Practice Name]
Department (if known): [e.g., “Health Information / Medical Records”]

Address:
[Street Address]
[City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]
Fax (if known): [Fax Number]

3. Recipient of Records

Please release records:

• To me (the patient)

• To the person or organization named below

Name of Recipient (person / doctor / law firm / insurer / other): [Name]
Organization (if applicable): [Organization Name]

Address for Records Delivery:
[Street Address]
[City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]
Fax (if acceptable): [Fax Number]
Email (for secure electronic delivery, if acceptable): [Email Address]

4. Description of Records Requested

Date Range of Records (check one):

• All available records on file

• Records from [MM/DD/YYYY] to [MM/DD/YYYY]

• Records related to the following incident, condition, or visit only:
  [Short description, e.g., “Motor vehicle accident on [Date],” “Knee surgery,” “DUI-related evaluation,” etc.]

Types of Records Requested (check all that apply):

• Complete medical chart / treatment records

• Visit notes / office notes / progress notes

• Hospital admission and discharge summaries

• Emergency department records

• Operative reports / procedure notes

• Laboratory results (blood work, pathology, etc.)

• Diagnostic test reports (X-ray, CT, MRI, ultrasound, etc.)

• Imaging on CD or other media (if available)

• Therapy records (physical therapy, occupational therapy, counseling)

• Medication / prescription history

• Immunization records

• Disability / work status notes and forms

• Billing records and itemized statements

• Other records (specify): [Description]

5. Delivery Method

Please provide my records in the following format (subject to facility policies):

Preferred Format (check all that apply):

• Printed copies by mail

• Printed copies for in-person pick-up

• Secure electronic copy (portal / encrypted email / secure download)

• Electronic media (CD / USB) if available

Delivery Instructions or Contact Person for Pick-Up:
[Name, phone number, and any special instructions]

6. Special Categories and Additional Authorizations (If Applicable)

Some types of records may receive extra protection under privacy or local laws. If you want them included (where allowed), check the relevant boxes below.

I authorize the release of records (if they exist) relating to:

• Alcohol or drug use, treatment, or dependency

• Mental health or psychiatric treatment

• HIV / AIDS testing, diagnosis, or treatment

• Genetic testing

• Reproductive health / pregnancy / family planning

If your jurisdiction requires separate or more specific consent for any of these categories, the provider may ask you to sign additional forms.

7. Purpose of Request

The purpose of this request is (check all that apply):

• Personal records and review

• Transfer of care / changing doctors

• Insurance claim or reimbursement

• Legal or court case (may include DUI-related or injury case)

• Disability or benefits evaluation

• Work or school documentation

• Other: [Describe]

8. Acknowledgments and Authorization

By signing below, I acknowledge and agree that:

• I am the patient named above, or I am legally authorized to act on the patient’s behalf.

• I authorize the provider or facility named in Section 2 to release the medical records described in this form to the recipient listed in Section 3.

• I understand that this authorization is voluntary, and I may refuse to sign it, but that may affect the ability to obtain or share records.

• I understand that once information is disclosed to the recipient, it may be subject to re-disclosure and may no longer be protected by the same privacy rules, depending on applicable law.

• I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. Revocation instructions should be sent to the provider/facility listed in Section 2.

9. Expiration of Authorization

This authorization will:

• Expire on [MM/DD/YYYY], or

• Remain valid for [__] months from the date signed below, or

• Remain in effect until the requested records are released or the purpose of this request is completed, unless revoked earlier in writing.

10. Signature

Patient / Authorized Representative:

Full Name: [Print Name]
Relationship to Patient (if not patient): [Parent / Legal Guardian / Power of Attorney / Other]

Signature: _______________________________
Date Signed: [MM/DD/YYYY]

Place Signed (City, State/Province): [Location]

11. For Provider / Facility Use Only (Optional)

Request Received By: [Staff Name]
Department / Title: [Department / Title]

Date Request Received: [MM/DD/YYYY]

Verification of Identity Completed: [Yes / No]
Method (photo ID, patient portal, other): [Describe]

Records Processed By: [Staff Name]
Date Records Sent / Made Available: [MM/DD/YYYY]

Method of Delivery (mail / fax / portal / pick-up / other): [Describe]

Fees Charged (if any, per facility policy): $[Amount]

Internal Notes:
[Space for any internal comments or tracking information]