Request Form For Access To Or Copies Of Medical Records

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MR #: ________________________________
ID Verified
Name: ________________________________
Kaiser Foundation Hospitals
__________
Date of Birth: __________________________
The Permanente Medical Group, Inc.
Staff Initials
Advised fees may apply
REQUEST FOR ACCESS TO OR COPIES
Initials: _________
OF MEDICAL RECORDS
(This is not to be used as a HIPAA Authorization)
IMPRINT AREA
1. The undersigned patient or patient’s legal representative hereby requests access to the Medical Records of:
_______________________________________________________________
Adult
Minor
1
PATIENT NAME
2.
For the purpose of: _____________________________________________________________________________________
3.
Medical Center/Facility locations for which I am requesting records: _______________________________________________
4.
I am requesting records be delivered in the following manner: (select ONE)
Electronic copies - Email ........................
>
Enter Email: _______________________________________
Electronic copies - CD ............................
>
Mail
OR
Pick up
Electronic copies - View .........................
>
Pick up (View)
Paper copies ............................................
>
Mail
OR
Pick up
OR
Fax (up to 10 pages)
Fax No: (_____) _____-_______
5.
Check the box(es) to specify which type of information is being requested:
2
Medical
Mental Health
2
Drug/Alcohol
HIV test results
6.
For the time period ___________________ to ________________________
7.
The record information being requested is:
PHYSICIAN OFFICE Records Requested
General Physician Office Records: Office Visits, Cardiology, Medications, Radiology/Lab/Pathology Results
Specific Physician Office Records: _________________________________________________________
HOSPITAL UNIT Records Requested
Inpatient/Emergency Stay Records
Surgery/Procedure Records
Specific Hospital Records: ________________________________________________________________
TEST RESULTS ONLY Requested
Radiology Reports
RADIOLOGY IMAGES (Handled separately, additional fees may apply)
Cardiology
Lab/Pathology
Specify Other Test Results: ______________________________________
1
I understand that if I am a parent making a request regarding records of a minor, I will not be shown entries for health care to
which, by law, the minor may consent without parental involvement. I understand that if I am a minor, I will be given access only to
those portions of my record describing health care for which I may consent, under applicable law, without the involvement of
parents.
2
I understand that records of mental health care or alcohol or drug abuse treatement may not be disclosed to me directly if the
health care provider determines that to do so would present a risk of significant adverse or detrimental consequences. I
understand that the provider may provide me with a summary of the requested records instead of copying or providing the original
records for examination. I understand I then may designate a physician, licensed psychologist, or clinical social worker to review
the record on my behalf.
PHONE NO.
PATIENT SIGNATURE
DATE
Initial OK to leave message
______
PATIENT REPRESENTATIVE SIGNATURE
PATIENT ADDRESS
DATE
RELATIONSHIP
CITY
STATE
ZIP

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