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This document is an authorization form for patients to request the release of their medical information from another healthcare organization to the University of Michigan Hospitals & Health Centers.

How to fill out request for outside records

How to fill out REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION

1. Obtain the REQUEST FOR OUTSIDE RECORDS form from your healthcare provider or organization's website.
2. Fill in the patient's personal information, including name, date of birth, and contact details.
3. Specify the healthcare organization you are requesting records from.
4. Clearly indicate the type of medical records needed and the dates of service involved.
5. Provide your signature and date to authorize the request.
6. If required, include any additional information or documentation that may support your request.

Who needs REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

1. Patients looking to obtain their medical records from another healthcare organization.
2. Caregivers or family members acting on behalf of the patient to request records.
3. Healthcare providers needing access to a patient's past records for continuity of care.

People Also Ask about

How do I word a request for medical records?

Making a health record access or correction request Your request should include: Your full name, address and date of birth. For access requests: a description of the information you're requesting and whether you require a summary, a full copy or if you want to view your records in person.

Can I release medical records from another facility?

Yes. If requested by an individual, a covered entity must transmit an individual's PHI directly to another person or entity designated by the individual.

How do I request someone else's medical records?

To receive a copy of your loved one's health records as a Personal Representative, you typically must ask for it in writing. In some cases, the hospital or doctor's office may have a form to request the records. Even with the legal right, however, this can prove to be a challenging process.

How do you write a formal request for medical records?

I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested (e.g., medical-history form you filled out; physician and nurses' notes; test results; consultations with specialists; referrals).]

For pdfFiller’s FAQs

What is REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

It is a formal document used to request patient medical records from a different healthcare organization to ensure continuity of care.

Who is required to file REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

Healthcare providers or facilities that need to obtain patient records from another organization to provide appropriate care.

How to fill out REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

The form should be completed with patient identification details, the records being requested, the purpose of the request, and signed by the patient or their authorized representative.

What is the purpose of REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

The purpose is to facilitate the sharing of patient information between healthcare providers to improve coordination and quality of care.

What information must be reported on REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

Required information includes the patient's name, date of birth, contact information, specific records requested, and the signature of the patient or authorized representative.