To make multiple requests (to give us permission to talk to, give out or gather protected health information) please submit an individual form for each request.Įxample: Your spouse wants to talk to your doctor and get your most recent imaging report. You would like to make more than one request ![]() This would allow us to gather your records from another doctor’s office.Įxample: Records from when you were seen at different doctor in Texas or another state. Some out of state organizations require you to authorize the release of your records to us. To give us (Fred Hutch) permission to get your records from other health facilities or doctors’ offices. Give us permission to get your medical records from another medical office Or, you would like to send this imaging report to your spouse or another specialist. To have your records given to you, a family member, caregiver or anyone else (insurance company or attorney).Įxample: You would like a copy of your most recent imaging report. Give us permission to share your medical records with others You can have multiple listed even though the table only looks like room for two. To give your family members, caregivers or anyone else coordinating your care permission to talk to your doctor and/or care team about your care (this could also include email communication).Įxample: Your spouse, child, or loved one can call and get your appointment schedule or confirm upcoming appointments. Give us permission to speak with your loved ones Viruses, Vaccines and Infectious Diseases.Institutional Partners & Collaborations.Office of Scientific Career Development.Coalition for Next Generation Life Sciences.Vaccine and Infectious Disease Division.Translational Science and Therapeutics Division.In these cases, you need to submit a Medical Records Release Authorization Form, which authorizes the mentioned party to receive the medical records on your behalf.īy signing the authorization form for release of medical records, you are officially requesting that your confidential health information be released or given to the party authorized & detailed by you in the form. At times, you may need to authorize someone else, such as your family members, relatives, or other doctors, to request medical records on your behalf. However, you may not always need a copy of those medical records yourself. With that form, your medical records will be shipped or emailed to you in a few days. ![]() In the section above, we’ve outlined what a Request of Medical Records Form is and how you can download the Free Medical Records Request template and edit it with your own information. Medical Records Release Authorization Form PDF Expert offers all the tools you need to work with PDFs in an intuitive experience. Using PDF Expert, you can fill out the blank fields in the form using your computer, without having to print out a copy and writing it by hand. You can download and edit this medical records request form PDF using PDF Expert - the best PDF Editor for Mac. * The templates here are provided for reference only and you should always talk to a professional for all legal matters Sample Medical Records Request Form Template ![]() This PDF template will tell you how to request medical records in writing, and also works as a generic medical records request form in most cases. A written request to ask for your medical records is generally the best option, as it ensures that your doctor retains a copy of your request and also helps in ensuring that everything goes as smoothly as possible.īelow is a sample letter requesting medical records that you can download as a PDF template and fill out a copy of the letter for requesting medical records from your doctor. Local & state laws vary from place to place, and so it is important to understand how to write a letter requesting medical records. In all these examples mentioned above, you have to put in a formal request by signing and submitting the medical records request form, which is also known as the ‘Letter to Request Medical Records’ template.ĭepending on where you live or what type of doctor you consult with, the rules and format for the medical records request form will be different. Your doctor or clinic cannot simply give out your medical history without your authorization. Click the green button to download the app.ĭue to the stringent confidentiality and privacy laws applicable in many cities, your medical records or documents cannot be simply handed over to anyone. Download the form here and fill it out using PDF Expert.
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