Medical Record Request Form

What is the purpose of a medical records request form?

A medical records request form template is a legal document that allows an individual to formally request access to their own medical records or, in some cases, those of a minor or another individual for whom they are legally authorized.

Every patient has an indisputable right to get access to their medical information as per the Health Insurance Portability and Accountability Act. Patients and their family members may need to request this information in various situations, including:

• transfer between medical facilities;
• submitting insurance claims;
• applying for state benefits, etc.

Neither federal nor state laws define the specific structure this request form shall have. However, some hospitals or medical institutions may occasionally require that requests be submitted in specific formats.

What to include in a medical records request template?

To ensure that your request is legally valid, it should include specific details and follow a structured format. The following elements are typically included:

Who is the Sender?

A sender in a letter template to request medical records could be:

• a patient; or
• a patient’s legal representative.

A patient can send this request by him or herself if the patient is 18 years of age or older, of sound mind, in good mental health, and capable of signing the document.

This letter template shall be signed and sent by a patient’s representative when:

• a patient is below 18 years of age (in that case a child’s parents or legal guardians shall sign the document);
• patient has severe physical incapacity (e.g., long-term illness, coma, etc.);
• patient delegates the right to issue and sign the document to their attorney; or
• patient is mentally incapable of issuing the document, so his or her guardian can do so on their behalf.

A medical record request template shall clearly state the full name, date of birth, and address of a patient, as well as its legal representative (if the letter is being sent by a representative).

Who is the Recipient?

The recipient of a medical record request is always a healthcare provider or institution that is in possession of a patient’s medical records. The recipient under the medical records request template could be:

• a doctor or medical practitioner; or
• hospital or medical institution.

The text of a letter shall include their full name, address, and contact details.

Scope of Authorization

The most critical element of every request for medical records template is a scope of authorization, or the list of exact medical information to which access should be given. A patient or their legal representative may request access to all or certain types of medical records (e.g., lab tests or surgery reports).

Despite the type of information being requested, the text of a letter shall explicitly address if a patient allows release of certain sensitive data, including:

• a patient’s HIV status;
• patient’s history of drug or alcohol usage;
• patient’s mental health and medication.

Therefore, the document should separately specify the patient’s consent or refusal to release such sensitive information.

Finally, a medical records request letter template should specify the full name of the individual or organization to whom access to a patient’s medical information shall be provided. It could be patients themselves, their family members, employers, insurance companies, etc.

Additional Details

Apart from the information listed above, a request for a medical records letter template shall also include:

• Reason for Disclosure. A patient or their representative has to explain the purpose for which information is being requested. The law does not limit the purposes for which access may be granted or denied.
• Duration. The maximum duration of the release given under the medical records request form template is one year. However, a person who issues such a request may limit its duration to several months only.
• Payment. Some hospitals or medical practitioners may charge an additional fee for providing access to medical records. Therefore, the letter should include a statement from the sender indicating their willingness to pay any applicable fees.
• Signature. The sender shall sign the document to make it legally binding.

How to customize a request template at FasterDraft?

To get a fully customized document, follow a few easy steps below:

1. Click the “Create Document” button.
2. Answer simple questions in the form.
3. Select a template’s format—Medical Request Letter Sample PDF or Word.
4. Make a payment.
5. E-sign, print out, and instantly use a customized document template.