Request for copy of Medical Records form

hhaynal

We are now putting into practice employees wishing to have a copy of their medical records on file, must put such request in writing. As such, instead of reinventing the wheel, I thought I would just ask the forum if anyone had a form for an employee to complete and sign requesting from the company a copy of his/her medical records?

hhaynal

REQUEST FOR COPY OF MEDICAL RECORDS


I, , hereby request that I be provided with a true and correct copy of:

[ ] All medical records

[ ] contained within my medical records (e.g., all lab reports, doctor’s return to work slip, etc.).

[ ] Other



Dated:
Signature




STATE OF :
:
COUNTY OF :


Before me, a notary public, on this day personally appeared , known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that s/he has executed the same for the purposes and considerations therein expressed.

Given under my hand and seal this day of , 200__.


Notary Public within and for the
aforesaid county and state
(seal) My commission expires

hhaynal

Here is what I drafted. The form is for former employees requesting copies of their medical records from our nurse practitioner. We felt it was needed to have the request in writing and notarized to confirm the identity of the requestor.

Sorry about the formatting....it just didn't adapt to the html format, I guess.

Constructive criticism is welcome as to the content of the request form.

Thanks.