Request to Access Medical Record
3215 N. Northhills Boulevard
Fayetteville, Arkansas 72703
Main Number 479.463.1000
Request to Access Medical Record
Please return completed form to WRMC Medical Records at (479) 463-1239
Patient Name:__________________________________________________________________________________
Birth Date:___________ Last 4 digits of your SSN:_________________ Phone:______________ Home/Cell/Work
Street Address:____________________________________City:_______________State:_________Zip:_________
Please Check the Types of Records to Be Accessed:
__Complete Medical Record
___Consultation
__Discharge Summary
___Pathology Report
__Operative report
___EKG
__History and Physical
___ER Record
__Other, Please Specify __________________________________
___Radiology Reports
___Laboratory Tests
___X-rays
___Billing
Dates of Service:
__ All dates of service
__ Date of Service From ____________________ To _________________________
Delivery of Records:
I request that a copy of my records be delivered to me by the following method:
__ In person pick-up
__ Mail to _______________________________________________________
Name of person to whom the records are directed
____________________________________________________________________________________
Street Address
City
State
ZIP
__ Fax to _____________________________________________
__ Secure Email to _______________________________________
__ Other _____________________________________________________________________________________
I understand that I am allowed to have access to these records and that, where readily producible, the information
will be provided to me in the form and format of my request. I understand that my request must be made in writing
and that it may be denied in certain limited circumstances.
I understand that my request will be acted upon within 30 days unless I¡¯m given written notification informing me
that an extension of up to 30 days is needed.
I understand that Washington Regional Medical Center cannot be responsible for the security of my records once
delivered according to my direction.
Created 3/23/17
Page 1 of 2
I understand that personal health information should not be sent via email in an unencrypted file and, although it is
my right to request such delivery, I understand that Washington Regional Medical Center strongly suggests that I
choose an alternate delivery method.
I understand that I will not be charged for this request.
__________________________________________________
Signature of Patient
__________________
Date
If you are acting as a legally authorized representative of the Patient, please complete the section below.
___________________________________________________
Printed Name of Representative
__________________________________
Relationship to Patient
(parent, legal guardian, etc.)
___________________________________________________
Signature of Representative
__________________________________
Date
Created 3/23/17
Page 2 of 2
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