Dmc Research Request For Medical Records Research Projects
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11 HIM 160
Research Request for Medical Records: Research Request for Medical
Attachment 1
Records Form
Page 1 of 1
RESEARCH REQUEST FOR MEDICAL RECORDS
Research Projects
Date of Request:
_________________
Name of Requestor: _______________________________
Telephone Number:
_______________________________
Department/Hospital/Organization: _______________________________
Research Project Name _________________________________________
IRB Number ______________________________
Project Expiration Date ______________________
Estimated Number of Charts: ________________
Cost of chart retrieval/refile: $3.00 per chart requested from off-site vendor
(excluding resident
and fellow research)
Estimated Invoice Amount
_________________
I acknowledge that I will pay the cost to retrieve and refile these medical records
_____________________________________________________
Signature of Department Sponsor/Person responsible for payment
Address
_______________________________________
City, State
_______________________________________
Telephone Number _______________________________________
------------------------------------------------------------------------------------------------------------
Internal Section
Return to Corporate Health Information Management
Iron Mountain Customer ID
______________
DMC Cost Center _______________
DMC Health Information Management
Reviewed” 9/09/2009
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Parent category: Medical