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23 Medical Request Forms for Healthcare Providers & Patients

Posted on May 6, 2022

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23 Medical Request Forms for Healthcare Providers & Patients

There’s nothing worse than slowing down medical procedures unnecessarily.

Lengthy processes and confusing paperwork slow your practice down and do nothing to help improve the patient experience. That’s why you need comprehensive and easy-to-use forms for patients, doctors, and all interested parties. 

With 123FormBuilder you’ll be able to create the medical request forms you need for your practice. Whether the patient is relocating, wants to change doctors, or needs access to confidential health records—you’ll be able to support patients in getting the healthcare they need. 

In order to facilitate the process of getting this important information, it’s essential to have the right medical request forms on hand.

Using our intuitive, secure form builder helps ensure you’re able to include all the necessary information in your forms. 

Let’s see how.

1. Authorization Request Form

authorization request form

Who needs this? 

Any patient that has various requests related to medical providers, medical facilities, physicians, specialists, or medical services will need this authorization request. 

What’s it for? 

An authorization request form helps identify patients and their healthcare providers, as well as communicate the patient’s requests. It’s a key step in transferring a patient from one healthcare professional to another under a health insurance plan.

Key benefits:

  • Fully customizable: use the drag and drop tool to build forms that are exactly what you need them to be.
  • Increase productivity with online forms: by allowing patients to fill out this form online from wherever they need to, you facilitate a better patient experience. 

2. Drug Prior Authorization Request Form

drug prior authorization form

Who needs this? 

Drug prior authorization request forms are used by doctors and healthcare providers that wish to request insurance coverage for drugs that are not listed on the insurance or state’s preferred drug list (PDL). 

What’s it for? 

This form explains why the drug is needed so the insurance can approve its administration and use. Any information about prior treatment with a different drug provided by the insurance should also be explained to further the rationale for the requested drug and treatment course. 

Key benefits:

  • Upload field: use 123FormBuilder’s drag-and-drop tool to add upload fields to your forms. Doctors will need to attach relevant clinical data and medical documents—make it easy to do just that. 
    • Automated email notifications: keep patients and other relevant parties in the loop with automated email notifications.
  • Conditional logic: let your form adjust and adapt based on previous answers to only ask for relevant information. 

3. Immunization Record Request Form

immunization record form

Who needs this? 

Patients, travelers, and guardians use these immunization information release requests to obtain their whole vaccination records to provide to daycare centers, schools, and other institutions. 

What’s it for? 

The immunization record request is used to request confidential details on an individual’s vaccination status. It includes details on the individual, as well as details on the requestor. 

Key benefits:

  • Go paperless: online forms are more environmentally friendly than paper forms. 
    • Avoid crowding medical practices: the fact that these forms can be filled from the comfort of their home, as well as be sent by email stops people from crowding hospitals and medical centers waiting rooms. 
  • Customizable thank you note: this way you can add a final note of appreciation at the end of the form.

4. Laboratory Test Request Form

laboratory test request form

Who needs this?

Doctors, physicians, and healthcare providers will use laboratory test request forms when they need a test to be performed by a laboratory. 

What’s it for? 

A laboratory test request is a form used by healthcare providers to ask for laboratory testing. It establishes the type of tests they need, the sample quantity that’s been provided, and all the details of the company or healthcare provider requesting the test. 

Key benefits:

  • Streamline processes with integrations: seamlessly integrate 123FormBuilder with your other tools to ensure seamless organization and simple data management.
  • Upload field: attach any relevant information by adding upload fields to your forms. 
  • Customize it to your needs: depending on the type of test you’ll need, you’ll be able to fully customize the form to suit your requirements. 

5. Medical Record Transfer Request Form

medical record transfer request

Who needs this? 

If a patient is changing doctors, moving to a new location, transferring to a different hospital or nursing home, or if they need their records to be sent to a specialist—they’ll need a medical record transfer request. This medical release form allows their records to be moved according to the law.

What’s it for? 

The medical record transfer request form–also known as the medical records release form, or authorization to release medical records–is a document that authorizes a patient’s records to be transferred from one health care provider to another. 

Key benefits:

  • Ensure forms are compliant: build HIPAA-compliant forms with 123FormBuilder’s Enterprise plan and ensure your forms adhere to all medical regulations.
  • Speed up processes: when you have everything online and can request and send all the information with a simple click you’re guaranteed to speed up transfers. 
  • Powerful integrations: easily store and manage forms by integrating 123FormBuilder with your existing workflow.

6. Medical Records Request Form

medical records request form

Who needs this? 

This is a key form for any doctor, nurse, or healthcare practitioner that needs to request medical records from a medical institution. 

What’s it for? 

This form helps identify the patient and the requestor, as well as the medical records needed. It also includes a section with legal information about the records requested. 

Key benefits:

  • Conditional logic process: not all requests will need the same information or attachments—create dynamic forms that adapt based on previous answers and inputs. 
  • Reduce human error: managing paper forms can lead to human errors that jeopardize the authorization process. Online forms reduce the likelihood of misplaced forms causing issues.
  • Easy to use: this form is widely used in the healthcare industry—it needs to be accessible and understood by everyone. 

7. Pathology Request Form

pathology request form

Who needs this? 

The pathology request form is needed by healthcare providers to request pathology services for a patient. 

What’s it for? 

This form gathers the physician and patient details, as well as the pathology tests that are needed and the reasoning behind their request. 

Key benefits:

  • Save time with integrations: fit the form to your medical practice processes by integrating it with the software you already know and use—like Google Drive, MailChimp, and more.
    • Secure online forms: thanks to our secure forms you’ll be able to keep confidential information private.
  • Upload files: adding a document like a pathology test is easy with the upload file option that the form builder offers.  

8. Patient Appointment Request Form

patient appointment request form

Who needs this? 

A patient appointment request is a form used by patients to request an appointment for a consultation at a specific medical center. 

What’s it for? 

Patients use this form to request an appointment with a healthcare provider. The form makes space for patients to include their personal details, reasons for appointment request, and availability—alongside some other key details.

Key benefits:

  • Easy to use: create a better patient experience with easy to use patient appointment requests. 
  • Thank you page: you can personalize the thank you page as you please to give a great final impression to your patients.
  • Automated email notifications: notify relevant members of staff when a new appointment request is received and processed. 

9. Patient Revocation Request

patient revocation request form

Who needs this? 

A patient revocation request is a form given to patients that wish to revoke, modify, or deny access to any of their protected health information (PHI). 

What’s it for? 

With this request form, patients can clearly state why they want to update the access and use of their PHI by other members covered under their policy. They can also specify any other changes to their privacy and confidential communication preferences. 

Key benefits:

  • Online forms: enable patients to update their confidentiality preferences from anywhere, at any time.
  • Conditional logic process: not all requests will need the same information or attachments. Create forms that adjust and adapt based on previous answers. 
  • 100% compliance: our forms allow you to add HIPAA compliance with the Enterprise plan. 

10. Personal Representative Request Form

personal representative request

Who needs this? 

Individuals that need to appoint someone else as a personal representative will need to fill this request. Patients use this form to enable someone to act on their behalf when they’re unable to when it comes to health benefits, protected health information, and so on. 

What’s it for? 

This form enables a patient to state who they are appointing as their personal representative and what powers they will have. 

Key benefits:

    • Automated integrations: ensure seamless data management by integrating 123FormBuilder with your existing workflow. 
    • 100% customizable: ask for the information you need by customizing this form to suit your medical practice needs. 
  • Thank you page: by customizing your thank you page you can provide a final piece of information, such as when the request will be processed or if there are any next steps.  

11. Prescription Refill Request Form

prescription refill request form

Who needs this? 

Patients who need a repeat prescription will require this prescription refill request form. It allows patients to request the medication they need without leaving the comfort of their own homes. 

What’s it for? 

This form enables patients to request that their repeat medication be sent to their doctor’s office or home address. The form includes patient details, medication details and dosage, and delivery preferences.

Key benefits:

  • Online forms: create forms that can be completed anywhere at any time, without the need to come into the practice.
  • Key integrations: streamline the entire process by integrating 123FormBuilder with the tools you know and love. 
  • Upload field: have your patients include all the necessary information by adding an upload field to your forms. 

12. Referral Request Form

referral request form

Who needs this? 

A referral request form is filled out by a doctor, nurse, or other healthcare provider who needs to refer a patient to a specialist doctor. 

What’s it for? 

This request gives the information of who is being referred, to whom, and under what reasons or circumstances—when specialized care is needed, for example. It also provides relevant medical information. 

Key benefits:

  • Automated email notifications: automatically notify relevant parties upon form submission to ensure everyone’s on the same page. 
  • Go paperless: referrals are so often asked for that keeping all of the paperwork on paper would be messy and waste a lot of paper. 
  • Conditional logic flow: create dynamic forms that adapt to previous responses to ensure you’re only asking relevant questions.

13. Request a Routine Medical Appointment Form

request a routine medical appointment

Who needs this? 

Patients that want to book a routine medical appointment require this form to communicate their needs. 

What’s it for?

This form enables patients to request a routine medical appointment with their GP. This form gives the medical practice all the information to find a time that works for both the physician and the patient. 

Key benefits:

  • Ease of use: let your patients easily request a routine medical appointment by using 123FormBuilder to create your form. 
  • Thank you page personalization: appreciate your patients and leave them with a positive impression of your practice.
  • Go paperless: reduce the environmental impact of your practice by taking your forms online.

14. Request for Access to Protected Health Information Form

request to access for protected health information

Who needs this? 

This is a key form for any individual that requires access to their protected health information (PHI).

What’s it for? 

This form is used to request any piece of protected health information. Patients state what information they want access to, sign in agreement to the terms and conditions, and await notice from their practice. 

Key benefits:

  • Automated email notification: notify relevant parties quickly and easily and speed up the process from start to finish. 
    • HIPAA-compliance: 123FormBuilder’s Enterprise plan makes sure you comply with medical regulations. 
  • Eliminate human error: with these online forms you’ll be able to make sure all the information is accurate and no mistakes are made. 

15. Request for Accounting Form

request for accounting form

Who needs this? 

Patients use this form to request details on the use of their personal health information over a period of time.

What’s it for? 

The request for accounting form enables patients to get an understanding of when and how their personal health information has been used. It details when PHI has been disclosed outside of for treatment, payment, or healthcare operations. 

Key benefits:

  • Ensure compliance: build HIPAA-compliant forms with 123FormBuilder’s Enterprise plan to guarantee that your forms comply with medical regulations. 
  • Automated PDF generation: keep records safely stored and easily accessible by creating a PDF with the request. 
  • Ease of set up: the drag and drop tool enables quick and easy form creation.

16. Request for Confidential Communications Form

request for confidential communications

Who needs this? 

This is an essential form for medical practices to have on hand for patient use. 

What’s it for? 

This form establishes permissions for communicating confidential and highly sensible information. It also establishes verification questions in order to increase the security of the communications. 

Key benefits:

  • Easy to build, easy to use: 123FormBuilder’s medical form templates are quick and easy to create and complete.
  • Ensure security: since these forms are all online you’ll make sure to keep all the sensitive information safely stored. 
  • Environmentally-friendly: going paperless saves you time and space, plus it helps the environment too!

17. Request for Diagnosis and Treatment Code Information Form

request for diagnosis and treatment

Who needs this? 

Health insurance providers and their clients—your patients—need this form following a diagnosis or treatment at a medical facility. 

The International Classification of Diseases assigns diagnosis codes, which describe an individual’s disease or medical condition. These codes are used on hospital and insurance forms.

What’s it for? 

The request for diagnosis and treatment code information form is needed to facilitate billing following a medical procedure. It’s used to request the specific diagnosis and treatment codes that are relevant for billing a patient’s health insurance provider.

Key benefits:

  • Easy form builder: create easy to use forms to ensure you can easily gather all the necessary information.
  • Integrate with existing workflow: streamline your processes by integrating these forms with your existing tools—such as GoogleDrive, MailChimp, Hubspot, and more. 
  • Automated notifications: notify the relevant team members when a form is submitted to speed up the entire process.

18. Request for Restriction of Use and Disclosure of PHI Form

request for restriction of use and disclosure of PHI

Who needs this? 

Patients that want to restrict the use and disclosure of their protected health information will need to fill in this form. 

What’s it for?

This request is needed to establish the desired restrictions on a patient’s protected health information. This form helps keep a well-structured record of the restrictions requested to ensure that medical practices are able to fulfill their legal patient confidentiality obligations. 

Key benefits:

  • Ease of use: let your patients know that they’re in control of their data and health information by making the request easy to fill and file. 
  • Ensure compliance: by using a HIPAA-compliant form tool—when on the Enterprise plan—you guarantee the safety of your patient’s data. 
  • Automated email notifications: in order to give your patients peace of mind you can send them a notification when their request has been received, reviewed, and approved.

19. Request Routine Dental Appointment Form

request routine dental appointment

Who needs this? 

A dental patient will need this form in order to book a routine dental appointment. It’s a key form for dental practices.

What’s it for? 

This routine dental appointment request form allows patients to take charge of their dental care with a routine check-up with their dentist. This form enables them to request a time that works, and outline what they expect from the appointment.

Key benefits:

  • Thank you page personalization: end the requesting process by appreciating patients with a warm thank you note. 
  • Easy to use: create a better patient experience with easy to use appointment request forms. 
  • Conditional logic: create dynamic forms that adapt to previous answers. For example, if a patient says they’ve never visited your practice, you’ll need to gather their personal details. If they’re an existing patient, you won’t. 

20. Request to Amend Protected Health Information Form

request to amend protected health information

Who needs this? 

Patients that would like to make an amendment to their protected health information (PHI) will need to fill in this form. 

What’s it for?

The request to amend protected health information form enables patients to communicate desired changes to their PHI record. Whether they need a change to be done on the PHI due to an error, or simply to update information, the request to amend protected health information is key for ensuring complete transparency. 

Key benefits:

  • HIPAA-compliant: 123FormBuilder enables you to build HIPAA-compliant forms that ensure you adhere to medical regulations. 
  • Thank you page personalization: end the requesting process with a message letting patients know that the change will be handled efficiently and in line with their requests. 
  • Easy to use: make it easy for your patients to fill in the information by using our highly intuitive forms. 

21. Request to Inspect a Copy of Clinical Record Form

request to inspect a copy of clinical record

Who needs this? 

This form is essential for patients who want a copy of their clinical records and test results to inspect. 

What’s it for? 

The request to inspect a copy of a clinical record enables patients to request a copy of their medical records for inspection. 

Key benefits

  • Create accessible forms: allow your patients to request a copy of their clinical record at any time, from anywhere. 
  • 100% customization: have complete control over the forms you build with 123FormBuilder’s comprehensive form builder tool.  
  • Go paperless: don’t waste time and money on managing paper forms–keep everything online!

22. Request to Obtain a Copy of Clinical Record Form

request to obtain a copy of clinical record

Who needs this?

Patients might need to obtain a copy of their clinical records when starting at a new school, dealing with insurance issues, receiving follow-up patient care, or for any other reasons. The request to obtain a copy of the clinical record lets them ask for exactly what they need. 

What’s it for? 

The request to obtain a copy of clinical records is needed in order to legally release confidential information. This includes things like expiration date of authorizations, description of sensitive information to be disclosed, and agreed format for the disclosure (physical copy, digital copy, delivered to a specific address, etc). 

Key benefits:

  • Conditional logic: let the form adapt to what the patient’s needs based on previous answers. 
  • 100% customization: have complete control over the forms you build to ensure they suit your needs and practice—you can even add your branding and logo.
  • Automated notification: notify the relevant health professionals when a new request is received.

23. Request to Restrict the Use of Confidential Information Form

request to restrict the use of confidential information

Who needs this? 

Patients use this form to request that their confidential information be restricted. If a patient would like to restrict the use of any of their confidential information they will need to request this and specify the reasons as to why. 

What’s it for? 

This form enables patients to request that their confidential information be restricted. It helps ensure the patient is able to communicate their wants regarding private information, and enables medical professionals and institutions to protect patient information when requested.

Key benefits:

  • Key integrations: speed up your form collection processes by integrating 23FormBuilder with your existing tools.
  • Ensure efficient data management: online forms can’t be lost or misplaced, and can be easily accessed by your entire practice.
  • Customizable thank you page: end the form with a thank you and a final piece of information for your patients. 

Wrapping Up on Medical Request Forms

Every medical practice or healthcare provider needs comprehensive medical request forms. Meeting patient needs means enabling them to easily request appointments, medical information, and more.

123FormBuilder makes it easy by enabling you to build the forms you need in minutes. Their HIPAA-compliant form builder—available with the Enterprise plan—ensures all your forms are regulation compliant, and the report dashboard enables you to gather insights on your practice’s day-to-day operations.

Sign up today to start building medical request forms that make life easier for you and your patients.

Medical Request Forms: Frequently Asked Questions

What is a medical request form?

A medical request form is a form used by healthcare professionals to request key information, treatment details, medication details, and more. There are a number of different medical request form templates, used by patients, doctors, and other interested parties.

What to ask for when asking for medical records?

All medical records requests should include the patient’s basic information–such as DOB, full name, address, email, telephone number—and a description of the medical information to be released. 

The form should also include terms and conditions regarding the disclosure of patient information, as well as the patient’s signature.

Originally published on May 6, 2022

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