Medical Records Request Form Template UK

The Medical Records Request Form Template UK is provided in multiple formats, including PDF, Word, and Google Docs, featuring editable and printable versions for your convenience.

Open – Template

Online – Template

Sample

Medical Records Request Form Template UK

Editable – Printable

PDF – 1 PDF – 2

Medical Records Request Form Template UK

1. Requestor Information




2. Patient Information



3. Medical Records Requested

4. Purpose of Request

5. Method of Delivery

6. Authorization

7. Signature and Declaration


PDF

WORD

Examples

Medical Records Request Form Template UK (1)
To:
[Name of the Healthcare Provider]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
From:
[Name of the Patient]
[Patient’s ID]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
Date:
[Date of Request]
Subject:
Request for Access to Medical Records
Dear [Healthcare Provider’s Name],
I am writing to formally request access to my medical records, as per my rights under the General Data Protection Regulation (GDPR) and the Access to Medical Records Act.
Details of Request:
I request copies of my medical records including, but not limited to, the following treatments and consultations:
[List specific treatments, dates, and providers if applicable]
Purpose of Request:
[State the purpose of the request, e.g., for personal records, transfer to another healthcare provider, etc.]
Preferred Format:
I would like to receive my records in the following format: [Digital (PDF, email) or Physical Copies (Postal)].
Additional Information:
Please let me know if you require any further information to process this request, or if there are any fees associated with providing my records.
Thank you for your attention to this matter.
Sincerely,
[Signature of the Patient]
[Name of the Patient]
Medical Records Request Form Template UK (2)
To:
[Name of the Healthcare Provider]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
From:
[Name of the Patient]
[Patient’s ID]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
Date:
[Date of Request]
Subject:
Request for Personal Medical Records
Dear [Healthcare Provider’s Name],
I am writing to request access to my medical records, according to my rights under GDPR and the Access to Medical Records Act.
Scope of the Records Requested:
I would like access to my complete medical history, including:
– Consultations and assessments
– Treatment records
– Prescriptions
– Diagnostic test results
[Specify any additional records needed]
Reason for Request:
This request is made for [Specify reason, e.g., personal health management, transfer to a new provider, etc.].
Format Preference:
Please send the records in my preferred format: [Digital (PDF via email or secure access) or Hard Copy (mailed)].
Clarifications:
If you need any more details or if there are fees involved in processing my request, please do not hesitate to contact me.
Thank you for your cooperation.
Sincerely,
[Signature of the Patient]
[Name of the Patient]

Printable

PDF – 1 PDF – 2

Medical Records Request Form Template UK