Download Medical Records Request Form for Free

The Medical Records Request Form is a pretty detailed and comprehensive template. The heading of this template is the necessary information of the patient. Then there is the concrete content that is required and the statement of acquiring the medical records. And the signature should be placed at the end of the file. This file is free to download. Whoever is in need of this template can visit our website and take it for your reference.

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MEDICAL RECORDS REQUEST FORM
Individual's Name:
Last First Middle
Home Address:
Home Telephone: Date of Birth:
I hereby request that the Practice provide me with [please check all boxes that apply]
a copy of the Requested Information” checked below:
My medical records.
Any other personally identifiable information used by
the Practice to make medical decisions about me.
Please check one of the following boxes:
I am only interested in accessing or obtaining a copy of Requested
Information relating to the time period ________ through ___________.
I am interested in accessing or obtaining a copy of all Requested Information
maintained by the Practice.
I understand that any information provided to me pursuant to this request will not
include (i) information compiled in reasonable anticipation of (or for use in) a civil,
criminal or administrative proceeding or as may otherwise be required by applicable law,
or (ii) if I am a parent or legal guardian requesting access to a minor’s information,
records related to certain categories of treatment as required by law (for example, a
minor’s treatment for venereal disease, the performance of an abortion operation, or care
and treatment to which the minor is permitted to consent--without needing to obtain
his/her parents/guardian’s consent first--and has so consented, for example, HIV testing,
STD diagnosis and treatment, chemical dependence treatment, prenatal care, care
received by a married minor, and contraception and/or family planning services).
I understand that the Practice may deny this request under limited circumstances
permitted by federal regulations governing the protection of personally identifiable health
information. I further understand that, except as otherwise permitted under applicable
federal law, I have the right to have a denial of my request reviewed by a licensed health
care practitioner selected by the Practice who did not participate in the Practice’s decision
to deny my request. If my request is denied again, I understand that I have the right to
have such denial reviewed by a medical record access review committee appointed by the
Commissioner of the Department of Health of the State of New York.
I understand that the Practice will notify me of its decision to approve or deny my
request to access or obtain a copy of the Requested Information within thirty (30) days of
receiving this request if the information is maintained or accessible on-site at the Practice
or within sixty (60) days if the Requested Information is not maintained or accessible on-
Medical Records Request Form
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