Medical Record Request Form

Medical Record Request

Medical record request form is used by the patient as a follow up of the already made request for release of copy of medical records. This form or letter clearly states about the legal requirement of providing the medical records, and gives a final date as deadline for receipt of medical records otherwise in case of not meeting this deadline, an attorney would be hired to do further needful.  This medical form is required to be filled out and sent by the patient to his doctor or healthcare provider in situations where the patient wants to change his doctor or needs this medical information to provide to some third person like insurance company etc. The medical information obtained through this form may be used to consult any other physician for treatment purposes.

When you submit your medical record request form, in few cases, a specific fee is charged by the health providers for releasing the copies of the record. When you submit request form to the concerned person or department, they will give you proper information about the fee and time to release the information that is related to your request.


This request form contains the complete information about the patient, the healthcare provider or hospital. The patient details include name, social security number, and date of birth. The body of the request form includes complete information about the medical information that is required to be obtained by the patient. This form should be complete in all respects because it is related to personal and sensitive medical information.

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Medical Record Request Form