Medical Records Request Form Template


What is a medical records request form?

Medical records request form is a document that is used to request for the medical records of a patient from a healthcare provider. This form includes the details of the specific medical records that are being requested along with the personal details of the patient such as their name and date of birth. It consists of the patient’s clinical information that has been accumulated by the physician or the medical facility staff. This clinical information can include diagnostic test results, physician notes, Z-Rays, and records pertaining to treatments and consultations. 

When is a medical record request form used? 

Medical records request forms can be used by many parties for a variety of reasons, such as taking a second opinion from another healthcare professional. In this case, the records are either requested by the patient or the healthcare provider that they have approached. Medical records are also requested in the wake of a legal matter, which is when a form needs to be filled out to access those records. 

Which parties are involved in a medical records request form? 

The patient, legal guardian, a healthcare provider with access to the records, and the individual/organization requesting the records are the main parties involved in the medical records request form. A medical records request form is required to be in compliance with the HIPAA guidelines and cannot be released without the written consent of the patient. 

What details are included in a medical records request form?

A medical records request form included the following details: 

  • Details of the patient (Name, Contact information, address, date of birth)
  • Details of the guardian (Name, contact information, relationship with the patient)
  • The patient’s written consent
  • Details of individual/organization that has requested the medical records 
  • Details of specific records requested (visit records, medical test results)
  • Reason/purpose for the request 
  • Third party disclosure
  • Authorization

What are the steps for filling out a medical records request form? 

The person requesting the medical records needs to first give basic information about themselves, such as name, contact details, date of birth, and the details of the healthcare provider who has the records. They need to specify the reason for requesting medical records and must specify which records they need particularly. It is only through this formal request that medical records can be accessed. 

Why is a medical records request form necessary?

Confidentiality and privacy of information are taken quite seriously in the healthcare industry, and medical records cannot be handed over casually. Releasing medical records without the patient’s permission can lead to severe legal penalties. Whoever wants to access medical records needs to put in a formal request with the concerned authority, and demonstrate clear intentions behind requesting the medical records. 

Can a medical records request be denied? 

Medical records requests can be denied if: 

  • It can potentially cause harm to the patient
  • Deemed to be inappropriate
  • There isn’t sufficient proof of identity or authorization
  • It is considered to be frivolous