Patient Health Information Request Form

The health information of the patient is collected for a variety of reasons. Regardless of the reason, the patient health information request form can be used to serve the purpose. This form is used by every person who wants to request access to the patient’s health information. This can be a patient himself.

Every hospital that treats a patient holds the health-related data of that patient. However, it is not easy to have access to the records and data of any patient in the hospital. Hospitals are usually bound not to release the information to anyone unless they are permitted to do so. However, if you want to get the information and you know that you need it for a legitimate reason, you can fill out the request form and make a request.

Patient Health Information Request Form

The Form File

Who can use the patient health information request form?

Anyone who needs easy access to the health information of the patient can fill out this form. The form is obtained from the hospital, and then people who want to make a request are asked to fill out the form and submit it.

It is important to note that filling out this form does not confirm that you will get approval of the request since the hospital will take various factors into account before making the final decision about whether to release the patient’s health information or not. Following are the people who can fill out this form:

The patient:

Sometimes, people fill out the form to get their medical details from the hospital because they want to share this information somewhere else where they can get better treatment or some sort of allowance based on their health.

The doctor:

Doctors also need to have access to the information of the patient to give the patient the most suitable treatment to the patient. For this, sometimes the doctor also fills out this form and makes a formal request for the sharing of the information.


Some legal cases also require lawyers to share the health-related record of the patient before the court to win the case. The court might ask them to share the data of the patient, and for this, they will have to ask the hospital to release the information.

What information can be included in the patient health information record form?

This form is divided into various sections, and each section of the form is used to collect details of a specific type. Following are the details that this form gathers:

The details of the requestor are:

The first section of the form gathers details about the person who is requesting the release of the information. These details generally include the name, position of the requestor, department to which the requestor belongs, contact number, the date on which the request is being made, etc. Depending on the specific needs, you can also add some more details.

Mention the purpose of making the request:

In most cases, the approval of the request largely depends on the purpose of making the request. So, when you fill out the form, you are required to mention the purpose of filling out the form and making the request. The purpose should be explained briefly and made sure that it makes sense to the management of the hospital.

Information about the data being requested:

There is some specific type of information that is generally requested, as not every type of information is useful for the requestor. For instance, you might need the health information of a patient from a particular year for a legal case. So, mention the year, the data that is required, and also the name of the department from which the data can be obtained.

You can also mention the name of a specific screening test or examination that was conducted, and you want to get the details extracted from the record. This also makes it easy for the management of the hospital to release the information, as in some cases, the information is so extensive that a hospital can’t share all of it.

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