Patient Access Request Form Template

PATIENT REQUEST FOR ACCESS TO MEDICAL RECORDS [ORGANIZATION NAME] Privacy Office [ADDRESS] [PHONE] [EMAIL] SECTION 1: PATIENT INFORMATION Patient Name (First, Middle, Last): _________________________________ Date of Birth: ___/___/___ Current Address: ____________________________________________________ City: ________________________ State: _______ ZIP: ______________ Phone: ____________________________ Email: ________________________ Social Security Number (optional): _________________________________ Patient ID Number (if known): ______________________________________ SECTION 2: AUTHORIZATION I am requesting access to my medical records as follows: [ ] I am the patient, and I am requesting my own medical records [ ] I am authorized to request records on behalf of the patient If you checked the second box above, please complete the following: Authorized Representative Name: _____________________________________ Relationship to Patient: ___________________________________________ Representative Address: _____________________________________________ Representative Phone: ___________________________ Proof of authorization attached: [ ] Yes [ ] No SECTION 3: RECORDS REQUESTED Please indicate which records you are requesting: Date Range: From ___/___/___ To ___/___/___ [ ] Complete medical record from entire date range [ ] Specific records only (check all that apply): [ ] Office visit notes [ ] Lab results [ ] Imaging reports [ ] Radiology images (X-rays, CT scans, etc.) [ ] Pathology results [ ] Surgical reports [ ] Hospital discharge summaries [ ] Consultation notes [ ] Medication list [ ] Immunization records [ ] Test results and reports [ ] Mental health/behavioral health notes [ ] Substance abuse treatment records [ ] Physical therapy records [ ] Billing records [ ] Insurance information [ ] Other: _______________________________________________ Any specific information you need excluded? If requesting others' information to be removed: ____________________ SECTION 4: FORMAT AND DELIVERY PREFERENCE How would you like to receive your records? [ ] Paper copy (mailed to your address) [ ] Electronic copy (email) [ ] Electronic copy on CD or USB drive [ ] Other: ___________________________________ Format preference for electronic records: [ ] PDF [ ] Word document [ ] Text file [ ] Excel spreadsheet [ ] Other: _______________ Preferred mailing address for records (if different from above): Address: _____________________________________________________________ City: ________________________ State: _______ ZIP: ______________ SECTION 5: FEES AND DELIVERY I understand that [ORGANIZATION NAME] may charge reasonable fees for copying and mailing records. The estimated fee for this request is: $[AMOUNT] [ ] I agree to pay the estimated fee [ ] Please contact me for cost approval before proceeding [ ] I request a fee waiver due to financial hardship Preferred method of fee payment: [ ] Check or money order [ ] Credit card [ ] Cash [ ] Deduct from account balance [ ] Other: _________________________________ Delivery preference: [ ] Standard mail (approximately 7-10 business days) [ ] Expedited mail (additional fee may apply) [ ] Electronic delivery (if requested format is electronic) SECTION 6: PATIENT AUTHORIZATION AND VERIFICATION I request access to the medical records described above. I understand that: - My request will be processed within 30 days of receipt - I may be contacted for clarification or additional information - Fees may apply for copying and mailing - [Organization] may deny access to certain records under HIPAA - I have the right to appeal any denials - The records released may contain sensitive information - I am responsible for the confidentiality and security of the released records [ORGANIZATION NAME] requires identity verification. Please provide a copy of one form of identification: [ ] Driver's license [ ] Passport [ ] State ID [ ] Other: ___________________________________ Patient Signature: _________________________________ Date: __________ SECTION 7: FOR AUTHORIZED REPRESENTATIVES If you are requesting records on behalf of the patient, please complete the following: I am requesting access to the above patient's medical records. I have the legal authority to act on behalf of the patient. I understand that: - This request may be denied if authorization cannot be verified - I must provide proper legal documentation of my authority - These records are confidential and must be handled appropriately Representative Signature: _________________________ Date: __________ Type of authorization (if other than listed): [ ] Parent/guardian (attach birth certificate or custody documents) [ ] Power of attorney (attach POA document) [ ] Healthcare proxy (attach proxy document) [ ] Conservator (attach court order) [ ] Other: _________________________________ SECTION 8: FOR OFFICE USE ONLY Date Received: ___/___/___ Received by: __________________________ Staff Member Name: __________ Patient Identity Verified: [ ] Yes [ ] No Method: _______________ Patient ID Located: [ ] Yes [ ] No Medical Record Number(s): ___________________________________________ Estimated Fees: $________________ Confirmed Fees: $_____________ Fee Payment Received: [ ] Yes [ ] No Date: ___/___/___ Processing Started: ___/___/___ Records Retrieved: ___/___/___ Records Copied/Burned/Emailed: ___/___/___ Shipping/Delivery: ___/___/___ Completion Date: ___/___/___ Processing Staff Initials: ________________ Supervisor Review: _________________________ Date: __________ Notes: _______________________________________________________________ SECTION 9: DENIAL RECORD (IF APPLICABLE) If this request is being wholly or partially denied, complete the following: Records being withheld: _______________________________________________ Reason(s) for denial: [ ] Psychotherapy notes [ ] Information compiled in anticipation of litigation [ ] Laboratory results as permitted under state law [ ] Other legal basis: ___________________________________________ Patient notification method: [ ] In person [ ] Mail [ ] Phone Patient appeal notification provided: [ ] Yes [ ] No --- PATIENT ACKNOWLEDGMENT UPON DELIVERY I acknowledge receipt of my medical records requested on ___/___/___ Patient Signature: _________________________________ Date: __________ If records were delivered electronically: I acknowledge receipt of my medical records via email on ___/___/___ Patient Name (Print): ___________________________________ Email Address Confirming Receipt: _____________________________________