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MEDICAL RECORDS REQUEST FORM
Last First Middle
Home Telephone: Date of Birth:
I hereby request that the Practice provide me with [please check all boxes that apply]
a copy of the “Requested Information” checked below:
My medical records.
Any other personally identifiable information used by
the Practiceto make medical decisions about me.
Please check one of the following boxes:
I am only interested in accessing or obtaining a copy of Requested
Information relating to the time period ________ through ___________.
I am interested in accessing or obtaining a copy of all Requested Information
maintained by the Practice.
I understand that any information provided to me pursuant to this request will not
include (i) information compiled in reasonable anticipation of (or for use in) a civil,
criminal or administrative proceeding or as may otherwise be required by applicable law,
or (ii) if I am a parent or legal guardian requesting access to a minor’s information,
records related to certain categories of treatment as required by law (for example, a
minor’s treatment for venereal disease, the performance of an abortion operation, or care
and treatment to which the minor is permitted to consent--without needing to obtain
his/her parent’s/guardian’s consent first--and has so consented, for example, HIV testing,
STD diagnosis and treatment, chemical dependence treatment, prenatal care, care
received by a married minor, and contraception and/or family planning services).
I understand that the Practice may deny this request under limited circumstances
permitted by federal regulations governing the protection of personally identifiable health
information. I further understand that, except as otherwise permitted under applicable
federal law, I have the right to have a denial of my request reviewed by a licensed health
care practitioner selected by the Practice who did not participate in the Practice’s decision
to deny my request. If my request is denied again, I understand that I have the right to
have such denial reviewed by a medical record access review committee appointed by the
Commissioner of the Department of Health of the State of New York.
I understand that the Practice will notify me of its decision to approve or deny my
request to access or obtain a copy of the Requested Information within thirty (30) days of
receiving this request if the information is maintained or accessible on-site at the Practice
or within sixty (60) days if the Requested Information is not maintained or accessible on-
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