Sample form requesting medical records

A request for medical records form includes details about the patient, doctor, and any information regarding the medical records that are being requested. A request for medical records is used when a patient needs to be updated on the current condition of his or her health. Patients may request medical records directly from their doctors, but most often they will contact their hospital, physician office, or other caregivers in order to release the information. These forms are under the protection of the Health Insurance Portability and Accountability Act (HIPAA).

1 minute to complete


A person who wishes to fill the form must be at least 18 years of age and have a valid government-issued photo ID.


Questions for Sample form requesting medical records



Patient Name

The answer should be a text input.

Patient ID

The answer should be a text input.

Date of visit

The answer should be a date input.

Specialist visited

The answer should be a text input.

Reason for requesting the medical record

The answer should be a text input.

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Here are some FAQs and additional information
Sample form requesting medical records

What is HIPAA?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.

What information is protected by HIPAA?

Health information such as diagnoses, treatment information, medical test results, and prescription information is considered protected health information under HIPAA, as are national identification numbers and demographic information such as birth dates, gender, ethnicity, and contact and emergency contact.

Where should a medical history be stored?

Patient records should be kept safely, confidentially, and securely at all times. The medical records should be stored securely in a fireproof cupboard or filing cabinet. The area where the medical records are kept should be protected from unauthorized access, theft and damage.

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