Customizable Request for Medical Records Form Template

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Patient Name

First

Last

Date of Birth

Patient Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Layout

Phone

MEDICAL RECORDS INFORMATION

Please release my medical records to:

Physician/Clinic's Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical Records Release Terms & Conditions

I accept the terms & conditions

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Patient's Signature

Date

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Do you need to accept medical records requests straight from your website? If so, then you should check out the Request for Medical Records Form Template from WPForms.

This form template includes all of the fields, questions, and consents needed to process medical records requests online.

Using the Request for Medical Records Form Template

If you operate a website for a physician’s office, lab, clinic, or any other medical setting, then you most likely send and receive requests for releasing medical records. And with WPForms, you can streamline this process even more. You might already gather these types of requests online, but a template like this can make it easier for you.

The information gathered for requesting medical records may be provided to you in additional places, but with this form template, you have all of the required data collected and stored in one place on your website. And, by using a template from WPForms, you can rest assured that the sensitive information listed on this form is kept safe and secure.

The Request for Medical Records Form Template first gathers the name, date of birth, and address of the patient whose medical records are being requested. The form also collects a contact email and phone number.

Then, this form template requires the information for releasing the patient’s medical records. The form user will provide the name and address for the physician, clinic, or other party the medical records will be released to. Then they accept the terms and conditions. Form users check a box to indicate their agreement to the terms and conditions, which you can edit and write in yourself.

In fact, every field on the Request for Medical Records Form Template can be edited and customized to meet your needs.

Finally, this form template requires a dated signature to submit the request, to further ensure the accuracy and security of the provided information.

Get started with WPForms today to create and customize your own Request for Medical Records Form. Signing up with WPForms gives you access to this and hundreds of other pre-made templates.

Our form templates let you create any kind of WordPress form in a few clicks.

You can select any template to view the demo and try it out. If it works for you, you can import it and publish it in minutes. Each WPForms template is fully customizable too. Our drag and drop form builder makes it easy to adapt any template to fits your business’ needs. When you use our form templates, you can easily: