Medical request forms are documents that organizations and medical institutions use for their patients and their clients who would want to request for a specific action to be taken. In addition, staff members and employees of a medical institution also use a particular type of medical request form to inform the admin about the needed tools and medical equipment.

Types of Medical Request Forms

Disability Management Solutions Medical Request Form – This form is the type of medical request form that insurance companies use to verify the disability claims of an insurance policyholder. The one who will be filling out the entry fields of this form type would be the policyholder’s physician or administering doctor. In the form, the policyholder will be referred to as the patient of the physician and his general information will have to be stated as well as the diagnosis of the physician and the patient’s restrictions which should be noted by the patient’s employer upon returning to work.

Disability Management Solutions Medical Request Form

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Size: 11 KB

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Flight Special Medical Needs Request Form – Flight passengers with special needs should be catered properly by the attendants and staff members of the airline company. And in order to know what specific needs the passenger should receive before, during, and after the flight, a flight special medical needs request form should be filled out by either the passenger or the guest or his legal guardian. The information to be disclosed in this type of request form should include the guest’s or passenger’s flight information, the medical needs to be catered, the reason for the request, the capabilities and restrictions of the passenger, and other information which can be useful to be known by the airline company’s staff members and attendants.

Flight Special Medical Needs Request Form

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Size: 227 KB

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Formula and Food Medical Request Form – Mothers who could not provide enough breastmilk to their newborns are the target users of this type of form. Specifically, a formula and food medical request form is a document to use for requesting baby formula and food to agencies or medical institutions who have programs which help children and women in need. The form has five parts which should be completed by the requestor. The first part of the form is intended for the patient’s information or the mother’s information which is then followed by the patient’s personal data to be disclosed in the second part of the form. The third and fourth parts of the form are for specifying the formulas and the supplemental food to be requested while the fifth part is to be filled out by the prescriptive authority.

Formula and Food Medical Request Form

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Size: 76 KB

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Home Care Medical Request Form – There are some patients whose conditions could be taken cared of in their own homes. However, in order for a patient to be released from a medical institution, a home care medical request form should first be filled out and be signed by the patient’s physician. The form will collect the patient’s details, medical¬†information, medication and medical treatment information, list of needed equipment and services, and the medical certification of the physician in lieu of the patient’s home care referral.

Home Care Medical Request Form

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Size: 78 KB

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Medical Exam Request Form – Immigrants and travelers will need to fill out this type of form to inform the immigration agency of a State or country about the need to undergo a medical exam. The form simply contains a textbox which has two options for the user of the form as to whether he will take a medical exam based on the requirements of his visa application or not.

Medical Exam Request Form

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Size: 99 KB

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How to Fill out a Medical Record Request Form

A medical record request form is a type of medical request form which should be used to inform an institution about the needs of an individual to obtain personal and confidential medical information or records. To use this form type, the steps below must be followed:

Step 1: Read and understand the instructions or guidelines listed in the form.

The instructions will contain the address or location where the completed form must be submitted along with the types of documents to be provided upon the submission of the request form.

Step 2: Specify the purpose of acquiring the medical records.

It is important that the requestor will indicate the reason why he will be needing the medical records, either of his own or of a patient. The reasons can include purposes related to research studies, medical billing needs, or to prove the necessity of a prescription and treatment.

Step 3: Complete the requestor information section.

This section is where the requestor’s name, contact information, and the date when the request was sent will have to be stated. In addition, the name of the supervising physician of the requestor can also be included.

Step 4: Indicate the specific range of data needed.

Every medical institution or clinic should be cautious in disclosing personal information to third parties. This is the reason why in a medical record request form, the requestor should be able to specify the type of data that he will be needing to meet his purpose. With this, the institution can conduct an eligibility verification procedure to determine whether or not the requested data should be provided to the requestor.

Step 5: Sign the form.

The signature block should have both the requestor’s printed name and signature, as well as the date when the form was being used by the requestor.

Medical Record Request Form

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Medical Request Form Sample

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Child Medical Records Request Form

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  • PDF

Size: 26 KB

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Medical Waiver Request Form

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  • PDF

Size: 27 KB

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Patient Medical Payment Request Form

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  • PDF

Size: 576 KB

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Temporary Medical Exemption Request Form

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  • PDF

Size: 211 KB

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Medical Request Form Tips

Medical institutions and organizations who will be using medical request forms should first validate the claims of their requestors, specifically those who are requesting to acquire medical products, services, and treatments to be provided in lieu of a medical or health illness and condition. On the other hand, document-preparers who will be making medical request forms from scratch for a medical institution should also know what specific data and information will have to be collected in the form since there are varying subjects to focus in each form type. And lastly, patients and requestors should fully disclose the information needed in the form to aid the institution or the provider in knowing what must be given.

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