MR / request copy
Medical records request
Blank request pack ready
This is a neutral request, not a legal notice. It does not prove authority to act for another person, guarantee release, or replace a provider’s form.
Date: 30 August 2026
To: Medical Records Department / authorised records contact
Provider or facility: ____________________________
Subject: Request for copies of medical records
Dear Sir/Madam,
I, ____________________________, am requesting copies of my own medical records.
- Patient name
- ____________________________
- Hospital/patient ID
- __________________
- Dates of care
- ____________________________
Records requested:
- ____________________________________________
Preferred delivery: ____________________________
Please tell me if your facility requires its own form, identity or authorisation check, a fee, or a different secure delivery method. Please acknowledge receipt and provide a contact or reference number for follow-up.
Contact details: _________________________
Signature: ______________________________
MR / follow-up copy
Request follow-up log
Keep this page with the copy you submitted.
- Provider or facility
- ____________________________
- Patient name
- ____________________________
Before submitting
- Used the provider’s current form or accepted request route, if required
- Verified the recipient and delivery channel before sending identity evidence
- Kept a copy of the submitted request and delivery proof
- Recorded the acknowledgement or reference number, if one was provided
Submission record
- Submitted on
- ____________________
- Method or location
- ____________________________
- Recipient or department
- ____________________________
- Delivery proof kept at
- ____________________________
- Acknowledgement/reference
- ____________________________
Follow-up log
1. Date: __________________
Contact or route: __________________
Note or outcome: ________________________________________________
2. Date: __________________
Contact or route: __________________
Note or outcome: ________________________________________________
3. Date: __________________
Contact or route: __________________
Note or outcome: ________________________________________________
When records arrive
- □ Keep the received originals unchanged.
- □ Record where each original is stored.
- □ Note any item the provider says is unavailable or requires another route.
This log records your own actions. It does not create a response deadline, prove authority, or replace the provider’s process.