Medical Record Request Form

 

Medical   R ecord   R equest   F orm  

Patient   N ame:   _ _______________________________________         D ate:   R equested:   _ ________________________  

DOB:   _ ______________________   A ddress___________________________________________________________  

Phone   N umber:_____________________  

 

Please   s pecify   i f   y ou’d   l ike   y ou   r ecords                 m ailed   _ ________             o r           f axed__________  

      * Note   i f   y ou   a re   r equesting   a   f ax   t he   r ecords   m ust   b e   l ess   t han   2 0   p ages.    

 

Send   M edical   R ecords   T o:    

Doctor/Facility   N ame:   _ ________________________________________________  

•

Address:   _ ___________________________________________________________  

•

City,   S tate   Z ip   C ode:   _ __________________________________________________  

•

Phone   N umber:   _ _____________________________________________________  

•

Fax   N umber:   _ ________________________________________________________  

•

 

Records   R equesting:   A LL   _ ________     S pecific   D ate   o f   S ervice   _ ___________     O ther:   _ ______________________  

___________________________________________________________________________________________  

 

Fee:   W e   f ollow   t he   I SMS   ( Illinois   S tate   M edical   S ociety)   g uidelines.      

MEDICAL   R ECORD   F EES   U NDER   H IPAA   A ND   I LLINOIS   L AW  

*JANUARY   2 014   U PDATE*  

Under   Illinois   law   the   amount   a   physician   can   charge   for   copies   of   medical   records   is   limited.   This   maximum  

amount   i ncludes   a   h andling   f ee   p lus   a   p er   p age   c harge   a nd   p ostage.  

 

Federal   law   in   this   area   supersedes   state   statute.   That   means   when   physicians   provide   records   directly   to   the  

patient   or   his   or   her   personal   representative   for   medical   care,   the   HIPAA   restrictions   apply.   However,   when  

providing   records   to   attorneys,   health   plans   or   other   entities   beyond   the   patient,   the   Illinois   schedule   (including  

the   s eparate   h andling   f ee)   c an   b e   c harged.  

 

State   a nd   F ederal   L aw  

Under   I llinois   l aw   ( Public   A ct   9 2-­‐228),   t he   a mount   a   p hysician   o r   o ther   h ealth   c are   p rovider   m ay   c harge   f or   c opying  

medical   r ecords   i s   l imited.   C opies   m ust   b e   p rovided   e lectronically,   i f   a vailable.   T he   m aximum   a mounts   a   p hysician  

can   c harge   f or   c opying   m edical   r ecords   i s   a s   f ollows:  

Medical   R ecord   F ees  

Formula   f or   c alculating   m edical   r ecord   f ees:   $ 26.38   h andling   f ee  

(For   p ersons   o ther   t han   p atients)  

PLUS   $ 0.99   e ach   f or   p ages   1 -­‐25,  

$0.66   e ach   f or   p ages   2 6-­‐50,  

$0.33   e ach   f or   p ages   5 1   t o   e nd;  

PLUS   a ctual   p ostage.  

I   a gree   w ith   t he   c harges   a s   o utlined   a nd   w ill   p rovide   p ayment   p rior   t o   t he   r elease   o f   m y   m edical   r ecords:     P atient  

Signature:   _ ______________________________________________________________