Sample Forms

Medical Record Request Form

September 29, 2014

Medical records are important documents for managing employees’ health and well-being at work. These records ensure that their employees are physically fit and capable of performing their jobs securely. The medical record request form is a standardized document that employers can use to request medical records from a doctor.

The form ensures proper identification of the employee and the doctor, as well as the employee’s consent for the release of their medical records.

Medical Record Request Form
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It includes specific information that is required to ensure the proper identification of the employee and the medical information that is needed. The records obtained after submitting a medical record request have a confidentiality clause, and doctors may not disclose them without the employee’s permission. Furthermore, the form cannot be used to obtain medical data for discriminatory purposes.

Contents of the form

The contents of the medical record request form are:

  • Employee information: This section includes the employee’s name, address, phone number, and date of birth. This information is necessary to ensure that the correct employee medical records are requested.
  • Doctor information: The doctor’s name, address, phone number, and fax number are included to make sure that the medical records are sent to the correct doctor.
  • Authorization: This section includes the employee’s authorization for the release of medical records to the employer. The employee must sign and date this section to give consent for the release of their medical records.
  • Reason for the request: The reason why the employer is requesting the employee’s medical records is mentioned here. This may include a workplace injury, a medical leave of absence, or a disability claim.
  • Date of service: This contains the employee’s most recent doctor’s appointment. This information is required to guarantee that the provided medical records are up-to-date.
  • Types of records requested: This section includes the types of medical records that the employer is requesting. This may include medical notes, lab results, and diagnostic imaging reports.

Use Cases

The medical record request form can be used in several situations:

  • Workplace injury: If an employee suffers an injury on the job, the employer may need to request medical records to assess the extent of the injury and the employee’s ability to return to work.
  • Medical Absence: In the case of an employee returning to the job after being on medical leave, the employer may need to obtain medical documents to ensure that the employee is physically fit to return to work.
  • Disability claim: The form to request medical records is also used by employees when they are to file a disability claim in their company, as records are prerequisites to ensure an employee’s eligibility for benefits.
  • Job-specific Requirements: Many jobs specifically require employees to be physically fit. For this purpose, an employee’s medical records can be submitted to guarantee that they are physically fit to execute their job safely.

Why is it important to use?

The medical record request form is important because it guarantees that the employee’s medical records are kept confidential and only authorized personnel have access to them. The form is significant in a workplace scenario where the employer has the information needed to manage the employee’s health and well-being at work.

Moreover, the form serves as a standardized document that employers and doctors can use to request and release medical data, ensuring that the process is efficient and streamlined.

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