Patient Health Information Request Form

Patient health information request form can be used by medical patient to request their physician or medical provider for access or any amendments to their personal protected health care information. This form can be either filled online or then printed or can be filled by hand after getting its print. This health information form is available in different sizes to be printed on all paper sizes.

This Patient health information request form is sent to the healthcare provider, attorneys, insurance companies or any other individual to get your information released. It is worth noting here that some health information like psychiatric, HIV test results and other relevant information, sexually transmitted diseases, domestic/substance abuse, genetic and records of sexual assault treatment etc are considered very sensitive and are protected by different laws. Therefore, if the patient is looking forward to get such information released, he has to be very specific in indicating this sensitive information on the given form by mentioning the respective information.


The Patient health information request form can also be used to rectify or amend your health information. If you think that the information with your doctor or physician is incorrect, you can send this information form by mentioning the correct information and with a request to rectify the incorrect health information. This healthcare form includes information about the patient like name, address, contact number, social security number etc. And this form is having specific issues mentioned which need to be ticked by the patient while filling it out. Information regarding type of request whether for release, access, copy, confidential communication, amendment, rectification or complaint is also mentioned in this form.


Preview and download option of Patient health information request form is given below.

Patient health information request form

Click here to download Patient health information request form