Transcription of IM201-A 062813 Medical Records Request Form
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Medical Records Request FormThis formisused to Request copies ofmedical Records . Only patients or their legal representatives may make a Medical Children s may verify your requests may be subject to a reasonable :Patient InformationName:_____Date of birth (MM/DD/YYYY): _____Address:_____Phone:_____City:_____S tate:_____ZIP:_____Part2:What information are yourequesting? (Markall that apply)Date(s) of service:_____ Clinic/ Outpatient Record. Clinic:_____Provider:_____ InpatientAbstract(includes face sheet, discharge summary, history and physical exam, operative and pathology reports, consultation reports,radiology reports and EEGs) Discharge Summary History/Physical Exam Operative Reports Pathology Reports Consultation Reports Radiology Reports & Images EKG/Cardiology Reports Lab Results Progress Notes Past/Present Medications Patient Allergies Billing(Claim)
Medical Records Request Form This form is used to request copies of medical records. Only patients or their legal representatives may make a medical record request. ... Inpatient Abstract (includes face sheet, discharge summary, history and physical exam, operative and pathology reports, consultation reports, radiology reports and EEGs)
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