Medical Records Request Form printable pdf download

MEDICAL RECORDS REQUEST FORM

Individual's Name:

Last

First

Middle

Home Address:

Home Telephone:

Date of Birth:

I hereby request that the Practice provide me with [please check all boxes that apply]

a copy of the “ Requested Information” checked below:

My medical records.

Any other personally identifiable information used by

the Practice to make medical decisions about me.

Please check one of the following boxes:

I am only interested in accessing or obtaining a copy of Requested

Information relating to the time period ________ through ___________.

I am interested in accessing or obtaining a copy of all Requested Information

maintained by the Practice.

I understand that any information provided to me pursuant to this request will not

include (i) information compiled in reasonable anticipation of (or for use in) a civil,

criminal or administrative proceeding or as may otherwise be required by applicable law,

or (ii) if I am a parent or legal guardian requesting access to a minor’ s information,

records related to certain categories of treatment as required by law (for example, a

minor’ s treatment for venereal disease, the performance of an abortion operation, or care

and treatment to which the minor is permitted to consent--without needing to obtain

his/her parent’ s/guardian’ s consent first--and has so consented, for example, HIV testing,

STD diagnosis and treatment, chemical dependence treatment, prenatal care, care

received by a married minor, and contraception and/or family planning services).

I understand that the Practice may deny this request under limited circumstances

permitted by federal regulations governing the protection of personally identifiable health

information. I further understand that, except as otherwise permitted under applicable

federal law, I have the right to have a denial of my request reviewed by a licensed health

care practitioner selected by the Practice who did not participate in the Practice’ s decision

to deny my request. If my request is denied again, I understand that I have the right to

have such denial reviewed by a medical record access review committee appointed by the

Commissioner of the Department of Health of the State of New York.

I understand that the Practice will notify me of its decision to approve or deny my

request to access or obtain a copy of the Requested Information within thirty (30) days of

receiving this request if the information is maintained or accessible on-site at the Practice

or within sixty (60) days if the Requested Information is not maintained or accessible on-

Medical Records Request Form