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Medical Records Request Form Template
Authorize and request your medical records in a clear, patient-friendly format for personal, insurance, or legal use.
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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]
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Learn more about
Medical Records Request Form Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
MEDICAL RECORDS REQUEST FORM TEMPLATE FAQ
What is a Medical Records Request Form?
A Medical Records Request Form is a written authorization that allows you (or someone you choose) to obtain copies of your health information from a doctor, hospital, clinic, therapist, or other healthcare provider. It typically includes your identifying details, the provider’s information, what records you want, and where they should be sent.
How do I use this form to request my medical records?
You fill in your personal details, identify the healthcare provider that has your records, specify which records or date ranges you want, choose how you want to receive them (mail, secure email, patient portal, or pick-up), sign and date the authorization, and send it to the provider’s medical records or health information department. Many providers accept requests by mail, fax, or secure upload — check their instructions.
What information should I include in a medical records request or release form?
A helpful medical records request form usually includes: your full name and date of birth, contact information, the name and address of the provider holding the records, a clear description of the records requested (for example, “all records from 01/01/2022 to present,” “imaging reports,” or “billing records only”), how you want them delivered, who is authorized to receive them, and your signature with the date of authorization.
Can I use this Medical Records Request Form for insurance, legal, or personal purposes?
Yes. This template can be used to request records for personal review, insurance claims, second opinions, legal or DUI-related cases, disability evaluations, or when changing doctors. You can send copies of the records to yourself, to a new provider, or (if you wish) directly to an attorney, insurer, or other authorized recipient. Always list the correct name and address for anyone you authorize to receive your records.
Are there any limits, fees, or timeframes for getting medical records?
In many places, healthcare providers are allowed to charge reasonable copying or processing fees and must respond within a set timeframe under local law or privacy rules (for example, HIPAA in the United States or other data-protection laws elsewhere). The exact limits, deadlines, and fee rules depend on your jurisdiction and the provider’s policies, so it’s wise to check their website or ask their records department if you have questions.
Can AI Lawyer help me draft a medical records request letter or form?
Yes. AI Lawyer can help you turn your details into a clear, well-structured Medical Records Request Form or cover letter, including the right sections and wording. You still decide which records to request and where they should be sent, and you are responsible for checking that the form meets any local legal or privacy requirements. For advice about your specific rights to access records, legal deadlines, or strategy in a case, you should consult a licensed attorney.
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