Get the free Medical Record Request - PedsNY.com

Pediatric & Adolescent Medicine, LLP Medical Record Request Form Please complete and send to previous pediatrician Child×runs Full Name: First Name Last Name First Name Last Name First Name Last

How to fill out medical record request

How to fill out a medical record request:

1. Begin by obtaining the necessary form. This can usually be done by contacting the healthcare provider or medical facility where the records are located. They may provide you with a physical copy of the form or offer a downloadable version on their website.
2. Carefully read the instructions provided on the form. Make sure you understand what information is required and how to fill it out correctly.
3. Provide your personal information first. This typically includes your name, address, phone number, and any other relevant contact details.
4. Indicate the specific medical records you are requesting. Be as specific as possible, including dates, the name of the healthcare provider, and any other relevant information that will help locate the records you need.
5. Specify the purpose of your request. Let the healthcare provider know why you need the medical records. This can range from personal use, legal purposes, insurance claims, or transferring them to a new healthcare provider.
6. If you are authorizing someone else to access your medical records, make sure to include their name and contact information and clearly state your consent. This is often required when a family member or legal representative is handling medical matters on your behalf.
7. Review the completed form for accuracy and completeness. Double-check that all the required fields have been filled out correctly, and make any necessary corrections before submitting.
8. Once the form is completed, follow the instructions provided on how to submit it. This may involve mailing it to the healthcare provider, dropping it off in person, or submitting it electronically through a designated portal.
9. Keep a copy of the completed form for your records. This way, you will have a record of the information you provided and can refer back to it if needed.

Who needs a medical record request?

1. Patients who want copies of their own medical records for personal use or to review their medical history.
2. Individuals who are transferring to a new healthcare provider and need their medical records to ensure continuity of care.
3. Individuals involved in legal proceedings, such as personal injury or disability claims, who require their medical records as evidence.
4. Insurance companies that need copies of medical records to process claims or determine coverage.
5. Healthcare providers who need access to a patient's medical records to provide appropriate care and make informed treatment decisions.
6. Authorized family members or legal representatives who are managing a patient's healthcare or legal matters and require access to their medical records.

Remember, it's important to follow the specific guidelines and procedures outlined by the healthcare provider or medical facility when filling out and submitting a medical record request.

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