Blank Request For Medical Records Form: Fill & Download for Free

Everyone else has already given the answer I was going to offer - serves me right for sleeping in.But I will emphasize one point which others have merely implied: at least in the US, you have a legal right to request a copy of your medical record - all of it, or any portion of it - and if another physician requires a copy of your medical record, the original facility has an absolute obligation to provide it.The law does allow the originating facility to require a nominal fee which is supposed to cover their costs of copying the record - not to punish patients for daring to request it, nor to make a profit on it. But bear in mind that copying a digital study like CT or MRI does not require some file clerk to manually photocopy a hundred pages of a chart - the images are burned to a CD or DVD, a much less labor-intensive procedure; and a blank DVD costs less than a dollar.If the second-opinion doc is part of the same network as the imaging center - and I mean professional network, not insurance coverage “network” - they may be able to access your images through the original facility’s own portal. However, this is not a guarantee; interoperability of electronic medical records across different facilities is a huge problem.You will be required to sign a consent form for sharing of your medical record, and some facilities will require that you go there in person and sign a piece of paper - ostensibly to protect your confidentiality, as required by HIPAA, because electronic requests could theoretically be coming from anyone, although one does wonder if this is simply another punitive deterrent.If you can choose a second reader before you request your records, the process will be much easier - just put that radiologist’s name, address and contact information on the form. I would suggest getting the name of someone at a local academic center, an expert in whatever body system you had imaged, because as Dr. Isaacs points out, radiology has become incredibly specialized - MRI of the spine, of the hip, and of the abdomen may be read by three different people, even though they all use MRI and may all have focused on the same general area of your body.The final issue is payment. I don’t know how many insurers will pay for a second opinion; the charge would reflect only a professional fee (for the physician reading the study), not a technical fee (for the technologist actually operating the machine, and the hospital or outpatient facility in which the machine is located) - since the technical part was already covered at the original center - but it could still cost a bit.Should you just ask for an informal review - a “curbside consult”, as we call them? Some radiologists will no longer offer these because of the malpractice liability - without a written record, they have no way to prove what they actually said, and a patient might misunderstand them and then sue. (This happened to a colleague of mine.)But I would get a formal interpretation anyway. An informal review will not be part of your medical record; if the second reader disagrees with the first, your insurer - and anyone who treats you afterwards - will only have the first report to go on. Doing something which is contradicted by that report would place a physician in legal and medical jeopardy, and the insurer would not cover treatments which the first report did not justify.One final observation: not every facility performs their studies the same way. A CT scan may be done with thinner slices in one place than another, and some facilities may use an IV injection which other facilities will omit. There are even more choices to make when doing an MRI exam. An academic specialist might tell you that the first examination, while reasonably adequate, was not optimal from their point of view - and recommend that you repeat the study anyway, with the different techniques used at their facility. I know this may just seem like a money grab, but some non-academic facilities are surprisingly behind the times (while others are state-of-the-art).If this happens to you - and I realize the irony of spending all this time and money to avoid a repeat scan, only to be told you need one anyway - I would ask the second reader how much better it would be to repeat the scan at their facility, and how much it would cost (assuming that your insurer will balk at paying for a repeat - “You just had one a week ago!”). Would they be taking the sensitivity of the test from 60% up to 90%, or only from 85% up to 90%? Academicians want to do the optimal study every time; you may have to decide if the extra percent is worth it financially.That’s an awfully long answer, but I wanted to take you through some of the process details before you set out on your journey. Good luck!

The law, as I understand it, favors the patient. The doctor owns the paper on which the medical record is written, but the patient owns the information.In the age of EMR the patient owns the information, you are entitled to a copy. In the world of paper records the doctor’s office is entitled to charge per page. Here is a state by state link to check the different fees allowed by each state.State Medical Records Payment RatesIn addition the office is within its rights to insist you complete a form documenting the request.If you like and respect your doctor spend a few moments thinking about what might bother him about releasing the records. It might be concern for you. Some doctors get paternalistic which I am not supporting but it’s better than cold and uncaring.So to create a paper trail and to ease the concerns may I suggest the following letter to accompany whatever official form the office requires.Dear DoctorI want to explain why I want a copy of my medical record. First off I am not working with an attorney or planning a lawsuit. I just want these records with me when I go to a doctor at the Major State Academic Medical Center Upstate (or whatever reason you have). I realize that you did not write my records in a way intended for me to read and that there is a risk I may misinterpret something you wrote. I would give you the benefit of the doubt on that score.I know paper is expensive and so it the time of your employees, so let me tell you I really only need records from June 2016 to the present and if your EMR can produce PDF copies, that would be easier. I can bring an empty thumb drive or a blank CD if that would help. If postage is inconvenient I can pick up the records in person.I want you to know that I have a high respect for your skill and experience and if that were not the case I would not want copies of this record.Please note that the release attached specifies progress notes, lab reports, xrays, other special studies and letters from other doctors about me.Also I am going to the Major State Academic Medical Center Upstate on July 20 so I would appreciate if I can pick up the records a week before that date.Did I ever get a letter like this from a patient? Rarely. But some type of nice letter is much better than a cold medical records release that provokes concern and defensiveness.

The Social Security Administration required me to change my name in order to receive my retirement benefit.That’s strange enough, but here is something even more peculiar:They required me to change my new name to the same as my existing name.Oh yeah, I know: you are wondering how that could even be possible to change your name without actually changing it. A HUGE WTF.I was wondering the same as I stood, drop-jawed, in front of the SSA office manager who said I needed to get a court order officially changing my name to the same name. “But it’s the same name!” I protested. “Sorry,” he replied. It is the only way we can conform our records.”I was beYOND indignation and outrage. I was overcome by morbid curiosity as to how this would all actually work out.NOW, you, dear reader, are probably thinking I am making this all up. But I am not. This story is true.So, I drove across town to the court house and appeared before the clerk of the court, to whom I reported, with great embarrassment, my stupid request to change my name from my name to the same name.“Oh,” the clerk said. “You’ve been to Social Security, haven’t you?”“What?” I gagged, “This happens often?”“All the time,” she said.So she gave me the forms, and a blank page she tore from a legal pad, on which I was to write WHY I needed to make the change.I did all that, and handed her the forms. That’s when I learned it would cost $50 in court fees. I didn’t have $50 with me, so I walked over to a nearby branch of my bank to withdraw that sum in cash. I mumbled something about needing it for a stupid change of name. And the teller winked at me and said, “Social Security, right?”Holy Cow! This was an actual thing!Back in the clerk’s office, I handed over my fifty big ones, and was told it would probably be about two weeks before the court order would be mailed to me. The judge was very busy.So, I took my leave, and on the 12-mile drive back home, I gradually became more and more angry about this state of affairs, and upon arriving home, promptly started typing a bitter letter to the acting Director of Social Security.And that’s when the phone rang. The caller was a staffer at the local SSA office who said they had found a new regulation which enable Social Security to change my name without a court order. I agreed to be there first thing, next morning.Which I was.There, the jolly manager had forms to complete, as I sat in the stiff chair by his desk.“OK,” he said, “What is your current name?” I told him.“And what is the name we need to change it to?” he queried. I told him.“But that’s the same name!” he said, casting a glance my way which indicated his assessment of me as the village idiot.“No shit!” I exploded. “If the new name is the same as the old one, why do we need to do this, at all?”“To keep our records up to date,” he replied, now glowing red with embarrassment.“And another thing,” I hissed through clenched jaws, “I had to pay the goddamned court $50 yesterday for a name change, at your insistence!”“OK, OK,” he went on. “Let me see your social security card.”“I can’t give you that, because your clerk took it from me yesterday and wouldn’t give it back because it had to be destroyed - remember!?”At which point, said clerk slimed her way around the corner, the card betwixt her extended thumb and index finger. Bitch.The manager compared the name on the card with the one on my birth certificate, which I had carried in the previous day to verify my identity, “just in case.”“Where did you get this card?” the manager asked.“From YOU GUYS, when I was about 13 years old!” I answered, testily. “Actually, my father brought it home to me. I needed a social number for my first job.”“But this has the same name as your birth certificate,” the poor man whispered. “But it is not the name we have in our system, for you.”At this point, the blood vessels in my throat were throbbing, my complexion had become a bright crimson, and the perspiration was pouring from my brow. I could hardly contain myself, and was deterred from throwing furniture only by the malevolent stare of a husky, armed security guard whose attention was now focused on my gathering eruption.“Look, let me work this out for you. YOUR people issued the goddamned card, 52 years ago. If your internal records don’t match the name on the card, which is obviously my correct name, then that’s your screw-up, not mine. So change your internal records, OK?And another thing. You might want to think about the evident dozens or maybe hundreds of people you have sent downtown for a name change owing to the same kind of mistakes you have made. The people in the clerk’s office and even the goddamned bank all realize how perfectly ridiculous this is, and how seemingly impossible it is to change.”A period of silence followed, as the manager, whose shirt was now slimy and darkened by his own perspiration, considered this debacle.Finally, he said quietly. “OK, you’re right. It is totally our fault. We’ll change the records, and set up your benefits. I’m giving you a NEW card, too, which will indicate your actual name based on the corrected records. And I’m giving you a check, right now, for $50, to reimburse you for the court fees.And thus, the matter was concluded, on his apology and a handshake. I took my leave, drove back to the court clerk’s office, and canceled the name change.“Glad you got it worked out, sir,” the clerk chirped. “But I’m sorry, we can’t refund the fee.”“No problem,” I replied, and held out my reimbursement check for her to see.End of story. All of it true. Every word of it.[Edit] Additional details and to answer some of the questions in the comments:Lead-up: Something else that made this situation unusual and remarkable was the fact that I had, just the day before, “signed up” for Medicare on-line with no problems whatsoever; it took just a few minutes and went smoothly. Thus I immediately attempted to sign up for Social Security in the same way.If I recall correctly, the screen of questions to properly identify me was the same - “Perfect,” I thought. But then, the “problem” message appeared and I was given an 800 number to call. The woman who answered was prompt, very courteous, helpful and efficient. She instructed me to take my birth certificate to the local SSA office to establish my identity and that the matter would be quickly resolved. Of course, as you now know from reading the above, it didn’t work out, that way. In fact, when I reported her instruction to the local staff, they all nodded “knowingly,” and said the people who handle phone calls just don’t know what they are talking about.Did someone steal my SS number? Evidently, not, inasmuch as there was no record of any other attempts to file under my number.Why didn’t I file a report with someone? In fact, I did complete the letter I had started, and was able to report the matter as resolved in my case, but warned that my case may simply be one example. I did receive a reply from the office of the director, who indicated the matter was being referred for investigation. But I heard nothing more.How did this happen? No way to know, for sure, although Social Security blames a change in computer systems, for it. But here’s what I think: My card was issued before the system records were totally automated. Thus the card I was given was manually typed at the local office, and an entry on some computer source document was made separately. The error in my name either occurred on that document, or when a key punch operator entered it into the master file later. I don’t even know what, exactly, the error actually was.Why didn’t I notice the error long before I filed for benefits? For the simple reason that MY only record was the card itself, which was correct. I had no way to see, and no reason to see, their office records. In addition, there was never a problem matching the number to my name on such forms as income tax returns or health and medical records. Finally, the annual advice from Social Security of my benefits (received long before my eligible age) always showed my correct name and number.DID SOCIAL SECURITY REALLY REIMBURSE ME FOR MY COURT FEES? Yes, they did. And it was voluntary on their part. I never suggested it.WHAT’S THE TAKE AWAY? HOW CAN YOU AVOID A SIMILAR CATASTROPHE? My opinion is that any holder of a social security card should verify name and number with the SSA before eligibility for benefits.Hope any of that helps.