Medical Records Request Form

Medical Records Request Form Patient Information Full Name: Alice M. Johnson Date of Birth: 15/03/1980 Address: 42 Elm Street, Anytown, AB1 2CD Phone Number: 07700 900345 Email Address: alice.johnson@example.com Requesting Party Information (if different from patient) Full Name: David L. Johnson Relationship to Patient: Spouse Phone Number: 07700 900567 Email Address: david.johnson@example.com Records Requested Type of Records: Full Medical History, Lab Results, Imaging Reports (X-rays, MRI) Dates of Service: 01/01/2020 to 31/10/2024 Provider(s) from whom records are being requested: Dr. Eleanor Vance (General Practice), Dr. Michael Chen (Cardiology), Anytown Hospital Radiology Department Purpose of Request: Continuing Medical Care Delivery Method Preferred Delivery Method: Secure Email (encrypted PDF) Alternative Delivery Method: Postal Mail Authorisation I, Alice M. Johnson, hereby authorise [insert name of medical practice/hospital] to release the medical information specified above to David L. Johnson. I understand that this authorisation is voluntary and I may revoke it at any time by providing written notification. I also understand that the information disclosed may be re-disclosed by the recipient and no longer protected by federal privacy regulations. Signature of Patient/Legal Guardian: Alice M. Johnson Printed Name: Alice M. Johnson Date: 01/11/2024 For Office Use Only Date Received: 01/11/2024 Records Processed By: Sarah Williams Date Fulfilled: 05/11/2024 Method of Delivery: Secure Email Tracking/Reference Number: MRR-2024-1101-001 Notes: Patient's spouse requesting records for new primary care physician. Consent confirmed via phone with patient. Records sent to provided secure email address.