Get the free Medical Records Request Form - Orthopedic Surgery, PC

Thomas R. Cadger, MD, FA AOS Ned B. Armstrong, MD Bennett J. Axel rod, MD, PhD, FA AOS David A. Stokes, MD, FA AOS Than L. Boo, MD, FA AOS Mandy C. Stout, PA-C Nicki Peters, PA-C Jenny Smith, PA-C

How to fill out medical records request form

1. Start by obtaining a copy of the medical records request form from the healthcare provider or facility. This form may be available on their website or you can request it in person or over the phone.
2. Fill out your personal information accurately and completely. This usually includes your full name, date of birth, address, phone number, and email address.
3. Include the name and contact information of the healthcare provider or facility from which you are requesting the medical records. This may include the name of the doctor, hospital, or clinic, as well as their address and phone number.
4. Specify the time period for which you are requesting the medical records. It is important to provide dates or a general timeframe to ensure that the healthcare provider knows which records to retrieve.
5. Clearly state the purpose of your request. Explain why you need the medical records and what you intend to use them for. This information helps the healthcare provider understand the context and urgency of your request.
6. If there are any specific documents or types of records that you require, mention them explicitly. For example, if you need copies of x-ray images, test results, or surgical notes, make sure to mention it on the form.
7. Indicate how you would like to receive the medical records. You may have options such as receiving them electronically via email, by regular mail, or by picking them up in person.
8. Provide your signature and date on the form to acknowledge that you authorize the release of your medical records.
9. Make sure to keep a copy of the completed form for your records before submitting it to the healthcare provider or facility.
10. Who needs a medical records request form? Individuals who want to access their own medical records, authorize their healthcare providers to release their records to another party, or request medical records on behalf of a family member or loved one may need to fill out a medical records request form. It is also commonly required for legal or insurance purposes when there is a need for a comprehensive medical history.

For pdfFiller’s FAQs

What is medical records request form?

Medical records request form is a document used to request copies of a patient's medical records from healthcare providers.

Who is required to file medical records request form?

Anyone who wishes to obtain copies of their medical records or request them on behalf of someone else.

How to fill out medical records request form?

You can fill out a medical records request form by providing your personal information, specifying the records you need, and signing the form.

What is the purpose of medical records request form?

The purpose of the medical records request form is to ensure patients have access to their medical information and can request copies for various purposes such as treatment, insurance claims, or legal matters.

What information must be reported on medical records request form?

The information required on a medical records request form typically includes the patient's name, date of birth, medical record number, the specific records being requested, and the reason for the request.

How can I send medical records request form for eSignature?

When you're ready to share your medical records request form, you can send it to other people and get the eSigned document back just as quickly. Share your PDF by email, fax, text message, or USPS mail. You can also notarize your PDF on the web. You don't have to leave your account to do this.

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