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Medical Records Request Fill out the template

Medical Records Request

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Last revision
Last revision 08/23/2019
Formats Word and PDF
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Size 3 pages
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Last revision: 08/23/2019

Size: 3 pages

Available formats: Word and PDF

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Medical Records Request

This Medical Records Request document is used by a Patient to request that a Healthcare Provider who has treated them release their medical records to a specific Recipient. Medical records contain sensitive and personal information and are considered protected and confidential. Patients generally have the right to their own medical records and the right to dictate who else shall have access to their records. Therefore, with a few exceptions, medical information can only be released with written authorization from the Patient (or their authorized representative). This document is used both to request and authorize the Healthcare Provider to release this information.

How to use this document

This document is made up of two sections. The first section is a letter from the Patient to the Healthcare Provider requesting that they release the medical records. This section includes important information such as the Patient's contact information, the reason for this request, and any alternate names under which the medical records may be filed. The second section is an Authorization of Medical Records Release form. This form gives the Healthcare Provider permission to release medical records to a specified Recipient. This section includes necessary information including information identifying the Patient, the name and contact information of the Recipient of the medical records, and specific authorization to release medical information related to especially sensitive conditions (e.g. HIV status, mental health treatment, substance abuse/addiction).

Many Healthcare Providers have very specific procedures regarding the release of medical records due to confidentiality concerns. The Healthcare Provider may have a specific form the Patient is required to submit to authorize the release of records. However, the form included with this document is a general purpose authorization that will work in many circumstances.

Once this document is completed, the Patient should sign both the letter and the Authorization of Medical Records Release form. The Authorization must be signed in two places: 1. a signature authorizing the release of specific records related to especially sensitive areas and 2. a signature related to the entire form. The Patient will send this signed document and keep a copy for themselves to keep in their personal records.

Applicable law

Both federal and state laws control the keeping and release of medical records. Federal law dictates the release of records that are generated in relation to the treatment of substance abuse/addiction. These laws also treat HIV/AIDS related information and medical health treatment records separately. These records are given additional protection due to the stigma associated with these conditions. These laws encourage diagnosis and treatment by decreasing the fear of public disclosure of this potentially sensitive information and any resultant discrimination or retaliation. These laws require a patient or their representative to specifically authorize the release of these categories of information rather than relying on a general release of all medical records.

Most states have laws specifying that medical records are the property of the Healthcare Provider who generates, stores, and maintains the information. Therefore, typically, only copies of medical records are released and the Healthcare Provider maintains the original record. Providers may charge a fee for copying and sending the records but are barred by federal law from denying the release of the records due to any the Patient's outstanding medical bills.

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