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Patient Label Page 1 of 1 Patient Request to Access Medical Records Form #CHCR-001 rev. 08/11 Patient Request to Access Medical Records Form AUTHOR Name of Facility/Entity: Patient s Full Name E-mail

How to fill out patient request to access

How to fill out a patient request to access:

1. Start by downloading or obtaining the patient request to access form. This form is typically available on the healthcare organization's website or can be requested from the medical records department.
2. Begin by providing your personal information, including your full name, date of birth, address, contact number, and email address. This information is essential for identification and communication purposes.
3. Next, specify the type of information you are requesting access to. This can include medical records, test results, imaging reports, or any other relevant healthcare information. Be as specific as possible to ensure you receive the correct documents.
4. Indicate whether you require physical copies of the requested information or if you are willing to receive them electronically. If you prefer electronic copies, make sure to provide your preferred format, such as PDF or encrypted email.
5. If you have any special instructions or requirements, such as the need for information in a language other than English or accommodation for disabilities, make sure to clearly state them in the appropriate section of the form.
6. When completing the form, double-check that all the provided information is accurate and up to date. Inaccurate or outdated information may cause delays in processing your request.
7. Finally, sign and date the form to certify that the information provided is correct to the best of your knowledge. Some forms may also require a witness or notary public signature, so make sure to check if any additional signatures are necessary.

Who needs a patient request to access:

1. Any individual who wishes to access their own medical records or healthcare information may need to submit a patient request to access. This is common when patients want to review their medical history, obtain copies of their test results, or share their records with another healthcare provider.
2. Family members or legal representatives who have obtained proper authorization may also submit a patient request to access on behalf of a patient. This can be applicable for parents seeking their child's medical records or individuals acting as healthcare proxies for someone unable to make decisions on their own.
3. Researchers or individuals involved in legal proceedings may need to submit a patient request to access specific medical records for their studies or cases. In these situations, additional documentation or permissions may be required to ensure the confidentiality and privacy of the patient's information.

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