Consumer Engagement & Personal Health Information

Patient Request Model Form 

07-06-2017 13:48

The American Health Information Management Association (AHIMA) is pleased to provide a model Patient Request for Health Information form to assist patients and providers in understanding and complying with patients “individual right of access” to their information as required by the Health Insurance Portability and Accountability Act (HIPAA). This model form is written at an 8th grade reading level. PLEASE NOTE: This is a suggested template and can be customized by providers and organizations to streamline your process when patients request their health information under HIPAA. The “Explanation for Use of AHIMA Patient Request for Health Information Model Form” - the reverse side of the model form - contains additional information, including links to related HIPAA specific requirements and resources to assist in a better understanding by patients and providers. AHIMA hopes you find this model form to be helpful in connecting patients with their health information. For more information regarding AHIMA, its mission, vision and work, or to become a member of AHIMA, please visit,


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01-15-2018 13:55

Thank you! This will be a very helpful form for me to use.
​Concur with Suzanne Goodell's comment that the form is too hospital centric.  I understand the comment about customizable; however, since over 60% of patient care/service is now delivered in the provider office practice setting not including a box to request physician practice records is a major oversight.

08-21-2017 08:27

​I am very disappointed the we didn't add the option to request physician practice records to this new request form.  As we move closer to population health management and consolidation of health systems, we must consider record requests that span the entire continuum of care.  the request form we developed is very hospital-centric.

07-27-2017 10:01

Thank you for sharing and making the process much easier.

07-25-2017 09:24

​Hi Lou Ann,
Thank you to you and the others who developed the form.  It is always easier to edit than to create.  A form that encompasses all care delivery sites would be more helpful to the patients.  Also, electronic delivery should be the first option rather than printed paper mailed to patient homes.  Many of our patients have embraced electronic delivery faster than HIM leaders.  Just a few thoughts...

07-24-2017 20:38

Hello Lou Ann! Is there any plan for an associated educational campaign or awareness process with this form? Will this be used by organizations and physician offices and will consumers be able to avail themselves to this form?
Curious where we go from here. Now that the form has been created, will people come to use it?
I think Suzanne brings up a good point about hospital-centric content. Will this be an evolving process of updating and educating?
Apologize for all the questions. These are things that come to mind.
​Good Morning Suzanne, this is a great question.  The form was developed by multiple volunteers from the Consumer Engagement and P/S practice councils.  The form was intended to be customizable for the user. If a particular provider finds that most of his patients want the entire record, he can always add that as an option, since this model form is only a suggested template and should be customized to meet the specific needs of a particular provider or healthcare organization.

07-20-2017 17:02

​I am disappointed that the model Patient Request form is so hospital-centric.  In the age of health systems with EHRs spanning the care continuum, why wouldn't  the check boxes for "what Records Do You Want"  include the option for physician practice record?.

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