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Request Medical Records
If you need to request your medical records please fill out this Request Medical Records Form template. After filling out the medical records request turn it into the front desk receptionist and she will process the Request for Medical Records as soon as possible.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes

Request Medical Records TemplateForm 1345
Format: Word PDF
Category: Medical, Hospital
Type: Request Form
Medical Records Request

Patientís Full Name: _____________________________________________________________________________

Home Address: _________________________________________________________________________________

City: _______________________________________________ State: ____________ Zip Code: ________________

Telephone Number: __________________________________ Date of Birth: ___/___/_____

I hereby request that your medical practice provide me with the following medical records:

___ A copy of the requested information checked below:

___ My medical records.

___ Any other information that you have that is personally identifiable and used by your medical


Please check one of the following boxes:

___ I am only interested in accessing or obtaining a copy of the requested information for the

following dates:

___/___/_____ - ___/___/_____.

___ I am interested in accessing or obtaining a copy of all the requested information that is

maintained by the practice.

Signature of Patient: __________________________________________________________ Date: ___/___/_____

Printed Name: _________________________________________________________________________________