Request for Patient access to
Medical Information
I hereby request
_______________________________ (name of healthcare provider) to grant me access
to my medical records.
Scope of access requested:
___ All the records
or
________________________________________________________________
(list disease, accident, dates of treatment and types of records
you wish to access)
Type of access requested:
___ Inspection, please call and let me
know when I may come in to view my records and what the charge will be if any.
___ Copies, I would like copies of
____ All records requested
____ All records except X-rays and tracings
___ Transfer
____ Copies of all records
____ Copies of X-rays and tracings only
To:
______________________________________________________________
__________________________________________________________________
(name and address of healthcare provider who is to receive the
records)
Charges
I understand that you may charge me
reasonable fees to copy or make my records available for inspection.
Signed____________________________________________
Date ___________
Print Name ________________________________________ Phone __________
(Form provided by Arthritis Insight )