application letter for medical report

Sample Letter to Request Medical Records from Doctors

In this article, I’ll guide you step-by-step on how to craft a concise, compliant, and courteous letter to request your medical records, sharing customizable templates , tips, and best practices from my own experiences.

Key Takeaways Understand Your Rights : Know that you have the legal right to access your medical records under HIPAA regulations . Be Specific : Clearly state which records you need, including dates of service, types of records, and any other specific details. Use a Template : A well-structured template can simplify the process, ensuring you include all necessary information. Follow Up : Be prepared to follow up if you do not receive a response within a reasonable time frame. Maintain Privacy : Always ensure your letter respects privacy laws and guidelines.

Step-by-Step Guide to Writing Your Letter

Step 1: start with your personal information.

Begin your letter by stating your full name, date of birth, and any other identifying information that your healthcare provider may require to locate your medical records. It’s essential to include your contact information as well, such as your phone number and email address.

Step 2: Specify the Records You Need

Clearly and concisely specify the exact records you are requesting. This could include dates of service, types of records (e.g., medical notes, lab results, imaging studies), and the format in which you’d like to receive them (e.g., electronic, paper copies).

Step 3: Cite Your Legal Rights

It’s helpful to mention your legal right to access these records under the Health Insurance Portability and Accountability Act (HIPAA). This shows that you are informed and serious about your request.

Step 4: Include Any Necessary Forms

Some practices or hospitals may require a specific form to be filled out to request medical records. Research beforehand and include any necessary completed forms with your letter.

Step 5: Sign the Letter

Ensure that you sign the letter. A physical signature is often required to process these requests officially.

Template for Requesting Medical Records

[Your Full Name] [Your Address] [City, State, Zip Code] [Phone Number] [Email Address]

[Doctor’s Name] [Practice or Hospital Name] [Address] [City, State, Zip Code]

Dear [Doctor’s Name or Health Records Office],

I am writing to request a copy of my medical records. I am requesting these records for [specify reason, such as personal record-keeping, consultation with another specialist, etc.].

Please include all records pertaining to my treatment from [start date] to [end date], specifically [list any specific records, tests, or types of information you need].

I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I am entitled to access my medical records. I would prefer to receive these records in [specify format: electronic, paper copy, etc.].

If there are any fees associated with the processing of this request, please inform me in advance.

Please let me know if you require any further information or documentation from my side to process this request.

Thank you for your attention to this matter. I look forward to your prompt response.

[Your Signature] [Your Printed Name]

Personal Tips from Experience

• Follow Up : If you don’t receive a response within 30 days, don’t hesitate to follow up. A phone call can often expedite the process.
• Be Polite but Persistent : Healthcare providers are often swamped with requests. A courteous tone paired with persistent follow-ups can make a difference.
• Understand the Fees : Be aware that while you have the right to your records, some providers may charge a fee for copying and mailing records.

Your Experiences

Have you had to request your medical records before? What was your experience like? I’d love to hear your stories and any additional tips you might have. Please share your thoughts in the comments below.

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Frequently Asked Questions (FAQs)

Q: What Information Should I Include in a Letter to Request Medical Records from Doctors?

Answer: From my experience, it’s essential to include the patient’s full name, date of birth, and specific dates of medical service. Also, clearly state the types of records needed, such as lab results, doctor’s notes, or immunization records. Don’t forget to mention your preferred method of receiving these records, whether it’s via email, mail, or in-person pickup.

Q: How Long Does It Take to Receive Medical Records After Requesting Them?

Answer: In my case, it took about 2-4 weeks to receive the medical records. However, this can vary depending on the healthcare provider’s process and the method of delivery you choose. It’s important to request the records well in advance of when you actually need them.

Q: Is There a Cost Associated with Requesting Medical Records?

Answer: Yes, sometimes. I’ve found that some healthcare providers charge a fee for copying and sending medical records. It’s a good idea to ask about any potential fees in your request letter or when you initially contact the healthcare provider.

Q: Can I Request My Child’s Medical Records Electronically?

Answer: Absolutely. Many healthcare providers now offer electronic delivery of medical records. In my experience, requesting electronic copies can be quicker and sometimes even free of charge. Make sure to specify this preference in your request.

Q: What If I Don’t Receive a Response to My Medical Record Request?

Answer: If you don’t receive a response, I recommend following up with the doctor’s office. A polite phone call or a visit can often expedite the process. In my experience, follow-ups are sometimes necessary to ensure your request is being processed.

Q: Are There Legal Restrictions on Accessing Medical Records?

Answer: Yes, there are certain legal restrictions under laws like HIPAA in the U.S. Generally, you have the right to access your own or your minor child’s medical records. However, access might be limited in certain cases, such as if the information could cause harm. In my journey, understanding these laws helped me navigate the request process more effectively.

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I found your guide on how to write a medical records request letter incredibly helpful and easy to follow, making what can be a daunting task much simpler for me

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Medical Records Clerk Cover Letter Sample

Increase your chances of scoring a job & find ideas for your new cover letter with this highly instructive Medical Records Clerk cover letter sample. Download this cover letter example as it is or rewrite it using our easy-to-use cover letter maker.

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Medical Records Clerk Cover Letter Sample (Full Text Version)

Vicky Petra

Dear Hiring Managers,

My name is Vicky Petra and I am pleased to be submitting my application for the Medical Records Clerk job within Saint George Hospital in Coventry. I believe that, if given the opportunity, I would be a valuable contribution to your team and institution and I am also confident that I would fully meet and exceed all your expectations for the role.

As stated in my attached CV, I am the Arden University graduate with a bachelor's degree in Healthcare Management which serves as an excellent evidence of my field knowledge. At the university, I was not only pro-actively involved in multiple extracurricular activities, including Psychology Society, TEDx Club, and Volleyball Club but I also won the Dean's Award once for achieving exceptional academic results.

On top of my education, I worked as a Medical Records Clerk at The Hillingdon Hospital for more than two years. There, I was mainly in charge of maintaining and organizing confidential documents and the patients' records and executing various daily clerical tasks. Besides that, I provided excellent service to clients, ordered missing supplies, coordinated the health screenings, and completed detailed medical reports. Throughout the years, I have demonstrated numerous times that I am an accuracy-oriented individual offering excellent analytical skills and the ability to think critically.

Next, I am a Certified Medical Assistant experienced with multiple important software programs necessary for the role, for instance, eClinicalWorks, EpicCare EMR, and EHR 24/7. Finally, I am a great team player with a proven track record of success in coordinating other employees and finishing all assigned duties within schedule. Thank you for your time and consideration.

Milan Šaržík, CPRW

Milan’s work-life has been centered around job search for the past three years. He is a Certified Professional Résumé Writer (CPRW™) as well as an active member of the Professional Association of Résumé Writers & Careers Coaches (PARWCC™). Milan holds a record for creating the most career document samples for our help center – until today, he has written more than 500 resumes and cover letters for positions across various industries. On top of that, Milan has completed studies at multiple well-known institutions, including Harvard University, University of Glasgow, and Frankfurt School of Finance and Management.

Edit this sample using our resume builder.

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• SF706A: Abdomen, Peritoneal cavity, Ascites / Fluid / Abscess collection, Imaging Guided Percutaneous Aspiration / Diagnostic Tap/Catheter
• SF819A: Abdominal Wall, Inguinal/Femoral Hernia, Unilateral Herniorrhaphy (MIS/open)
• SF820A: Abdominal Wall, Inguinal/Femoral Hernia, Bilateral Herniorrhaphy (MIS/open) - Day Surgery
• SF820A: Abdominal Wall, Inguinal/Femoral Hernia, Bilateral Herniorrhaphy (MIS/open) - Inpatient
• SF836A: Anus, Hemorrhoids, Hemorrhoidectomy with or without sigmoidoscopy
• SF723A: Appendix, Various Lesions/Abscess, Appendicectomy with Drainage (MIS/open)
• SF849A: Appendix, Various Lesions, Appendicectomy Without Drainage, MIS/open
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• SB826B: Bone (Upper Limb), Simple Implants, Removal (eg: K-wires, wires, pins, screws only)
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• SB709H: Hand, Flexor Tendon, Trigger Finger (Single), Release
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• SA709B: Breast, Various Lesions, Trucut Biopsy, ultrasound guided or stereotactic (multiple)
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• SA824B: Breast, Tumor (malignant), Simple Mastectomy with Axillary Clearance, with/without Sentinel Node Biopsy
• SA827B: Breast, Tumor (malignant), Simple Mastectomy with Sentinel Node Biopsy/ Axillary Node Sampling
• SA829B: Breast, Various Lesions, Trucut Biopsy
• SA707B: Breast, Tumor (Malignant), Wide Excision/ Lumpectomy/Segmental Mastectomy/ Partial Mastectomy, With Sentinel Node Biopsy/ Axiliary Node Sampling
• SA703R: Radiotherapy, Intracavitary Brachytherapy (Multi-channel): Cervix, Others
• SI704C: Cervix, Transcervical resection (TCR) Polyp (<2cm), hysteroscopic
• 2cm), hysteroscopic" href="/patients-visitors/bill-estimator/cervix/Pages/cervix-transcervical-resection-TCR-polyp-more-than-2cm-hysteroscopic.aspx"> SI705C: Cervix, Transcervical resection (TCR) Polyp (>2cm), hysteroscopic
• SI707C: Cervix, Various Lesions, Colposcopy, Laser Vapourisation/Loop Electrosurgical Excision Procedure/Laser Excision of Transformation Zone with Biopsy
• SI802C: Cervix, Cervical Incompetence, Cerclage
• SI803C: Cervix, Cervical Intraepithelial Neoplasia, Cone Biopsy with/without laser
• SF702C: Colon, Colonoscopy (diagnostic), fibreoptic with/without biopsy - Day Surgery
• SF702C: Colon, Colonoscopy (diagnostic), fibreoptic with/without biopsy - Inpatient
• SF703C: Colon, Colonoscopy (screening), fibreoptic with/without biopsy
• SF704C: Colon, Colonoscopy (diagnostic), fibreoptic with removal of polyp (single or multiple less than 1cm)
• SF705C: Colon, Colonoscopy (diagnostic), fibreoptic with removal of polyps (multiple more than 1cm)
• SF706C: Colon, Colonoscopy (screening), fibreoptic with removal of polyp (single or multiple less than 1cm)
• SF710C: Colon, Sigmoid, Sigmoidoscopy (flexible), Fibreoptic with/without biopsy
• SL700R: Retina, Laser retinopexy, complex (subretinal fluid, vitreous haemorrhage, multiple tears)
• SL700V: Vitreous, Intravitreal Injections
• SL701P: Photorefractive Keratectomy/Phototherapeutic Keratectomy (for diseased eye)
• SL704R: Retina/Macula, Grid and focal laser photocoagulation
• SL705E: Eye, Glaucoma drainage implants eg. Ahmed Valve implant, Molteno implant , Baerveldt Tube Shunt
• SL705R: Retina, Pan retinal photocoagulation
• SL706E: Eye, Glaucoma, Cyclodestructive procedures
• SL722E: Eyelids, Botox injections for blepharospasm & hemifacial spasm
• SL801I: Iris, Various Lesions, Laser Iridotomy
• SL801V: Vitreous, Various Lesions, Posterior Vitrectomy (pars plana/ sclerotomy/ lensectomy-extraction with Intra-ocular Lens Implant/ endolaser/ membrane peels)
• SL803C: Conjunctiva, Pterygium, Removal with conjunctival graft
• SL808L_SL809L: Lens, Cataract, Extraction with Intra-ocular Lens Implant (Unilateral) - Day Surgery
• SL808L_SL809L: Lens, Cataract, Extraction with Intra-ocular Lens Implant (Unilateral) - Inpatient
• SL809C: Cornea, Myopia, Phototherapeutic Keratectomy/Laser in-situ Keratomileusis
• SL815L: Lens, Various Lesions, Yag Laser Capsulotomy
• SL846E: Eyelids, Tumor, Shaving Excision
• SL718E: Eyelids, Various Lesions, Upper Blepharoplasty, Bilateral
• SF801G: Gallbladder, Various Lesions, Cholecystectomy (open or lap) - Day Surgery
• SF801G: Gallbladder, Various Lesions, Cholecystectomy (open or lap) - Inpatient
• SF710B: Endoscopic Retrograde Cholangiopancreatography (ERCP) With Sphincterotomy/Removal Of Stone/Insertion Of Biliary Stent
• SD707A: Arteriovenous fistula, angioplasty with/without stenting
• SD707H: Heart, Cardiac Catheterisation (left) and Intracoronary Pressure Wire without Percutaneous Transluminal Coronary Angioplasty (PTCA) - Day Surgery
• SD707H: Heart, Cardiac Catheterisation (left) and Intracoronary Pressure Wire without Percutaneous Transluminal Coronary Angioplasty (PTCA) - Inpatient
• 1 hr), with/without IVUS/FFR or other physiological studies" href="/patients-visitors/bill-estimator/heart/Pages/heart-PTCA-stenting-complex-with-withoutIVUS-FFR-or-other-physiological-studies.aspx"> SD712H: Heart, Percutaneous Transluminal Coronary Angioplasty (PTCA) + stenting (1 vessel) - Complex (defined as > 1 hr), with/without IVUS/FFR or other physiological studies
• SD714H: Heart, Primary Percutaneous Transluminal Coronary Angioplasty for ST-elevation Myocardial Infarction
• SD716H: Heart, Heart Block/Arrhythmia, Insertion of Dual chamber Pacemaker (permanent)
• SD731H: Heart, Valve (Repair / Replacement) - 1 Valve
• SD802H: Heart, percutaneous ablation of arrhythmia circuit or focus or isolation procedure involving 1 atrial chamber
• SD810H: Heart, Coronary Disease, Coronary Angioplasty (transluminal), with/without angiocardiography
• SD811H: Heart, Coronary angiography (Selective) - Day Surgery
• SD811H: Heart, Coronary angiography (Selective) - Inpatient
• 1 vessel)" href="/patients-visitors/bill-estimator/heart/Pages/heart-percutaneous-transluminal-coronary-angioplasty-stenting-with-without-ivus-ffr-or-other-physiological-studies.aspx"> SD713H: Heart, Percutaneous Transluminal Coronary Angioplasty (PTCA) + Stenting (More Than 1 Vessel), With/Without Ivus/Ffr Or Other Physiological Studies
• SD742H: Heart, Coronary Disease, Coronary Artery Bypass Graft (Open/MIS/Off Pump)
• SG802K: Kidney, Calculus, Extra Corporeal Shockwave Lithotripsy (ESWL)
• SG720K: Kidney, Various Lesions, Partial Nephrectomy, Laparascopic
• SA712S: Soft Tissue (Lower Limb), Contracture, Minor Release
• SB700H: Hip/Knee, Hip/Knee Therapeutic Arthroscopy
• SB701K: Knee, Ligaments/Meniscus/Cartilage/Bone combined, MIS ACL or PCL reconstruction
• SB703K: Knee, Ligaments/Meniscus/Cartilage/Bone combined, MIS ligament reconstruction with meniscal repair
• SB712K: Knee, Meniscus/Cartilage ( small defects ), MIS/open Mosaicplasty or OATS
• SB715K: Knee, Meniscus/Cartilage, MIS meniscal repair
• SB716K: Knee, Various Lesions, Primary Total Joint Replacement (Unilateral) with augmentation, requiring extra implants or bone grafts, open/MIS/navigated
• SB801B: Bone (Lower Limb), Deformities, Corrective Surgery with Internal Fixation with or w/o Fluoroscopy
• SB810K: Knee, Various Lesions, Primary Total Joint Replacement (Unilateral), open/MIS/navigated
• SF711L: Liver, Various lesions, Imaging Guided Percutaneous Biopsy (Focal lesions, targeted)
• SF814L: Liver, Various lesions, Imaging Guided Percutaneous Biopsy (Liver parenchyma, non directed)
• SC702B: Bronchus/Lung, Transbronchial needle aspiration of mediastinal lymph nodes, with or without Endobronchial ultrasound (EBUS)
• SC801L: Lung, Various Lesions, Repeat/Multiple/Complex Resections
• SC726L: Lung, Various Lesions, Lung Resection With Mediastinal Resection, Any Approach
• SC718T: Thorax, Various Lesions, Imaging guided Percutaneous Biopsy
• SF804T: Tongue, Tongue Tie, Release
• SF814P: Parotid, Tumor, Superficial Parotidectomy
• SJ701T: Thyroid, Various Lesions, Imaging Guided Percutaneous Aspiration / Biopsy
• SJ802T: Thyroid, Various Lesions, Hemithyroidectomy/Partial Thyroidectomy
• SM705T: Tonsils, Various Lesions, Removal with/without Adenoidectomy - Day Surgery
• SM705T: Tonsils, Various Lesions, Removal with/without Adenoidectomy - Inpatient
• SM716L: Larynx, Various Lesions, Direct Laryngoscope Examination With/Without Biopsy
• SM700I: Inferior Turbinate reduction (submucous diathermy oblique radiofrequency)
• SM700N: Nose, Nasoendoscopy/Nasopharyngolaryngoscopy (Single Or Repeat Examinations, During A 90 Day Global Period) - Inpatient
• SM700N: Nose, Nasoendoscopy/Nasopharyngolaryngoscopy (Single Or Repeat Examinations, During A 90 Day Global Period) - Day Surgery
• SH832P: Prostate Gland, Prostate, Benign Hyperplasia, Minimally invasive ablation
• SH835P: Prostate Gland, Various Lesions, Saturation Prostate Biopsy - Day Surgery
• SH835P: Prostate Gland, Various Lesions, Saturation Prostate Biopsy - Inpatient
• SA701S: Skin and Subcutaneous Tissue, Tumor/Cyst/Ulcer/Scar, Excision biopsy, removal of 2 or more or recurrent or complicated (adherent), excision
• SA702S: Skin and Subcutaneous Tissue, Tumor/Cyst/Ulcer/Scar, Excision biopsy, Lesion size more than 15mm in diameter
• SA800S: Skin and Mucous Membrane, Various Lesions, Excision Biopsy
• SA803S: Skin and Subcutaneous tissue(ear/nose/eyelid/face) complex lacerations, repair
• 3cm/Extensive Contaminated Wound, Debridement - Day Surgery" href="/patients-visitors/bill-estimator/skin/Pages/skin-and-subcutaneous-tissue-deep-more-than-3cm-extensive-contaminated-wound-debridement-day-surgery.aspx"> SA811S: Skin and Subcutaneous Tissue, Deep>3cm/Extensive Contaminated Wound, Debridement - Day Surgery
• 3cm/Extensive Contaminated Wound, Debridement - Inpatient" href="/patients-visitors/bill-estimator/skin/Pages/skin-and-subcutaneous-tissue-deep-more-than-3cm-extensive-contaminated-wound-debridement-inpatient.aspx"> SA811S: Skin and Subcutaneous Tissue, Deep>3cm/Extensive Contaminated Wound, Debridement - Inpatient
• 3cm, Saucerisation/lncision with Drainage" href="/patients-visitors/bill-estimator/skin/Pages/skin-and-subcutaneous-tissue-hematoma-carbuncle-cellulitis-similar-lesion-more-3cm-saucerisation-incision-with-drainage.aspx"> SA841S: Skin and Subcutaneous Tissue, Hematoma /Carbuncle Cellulitis/Similar Lesion>3cm, Saucerisation/lncision with Drainage
• 3cm/multiple) lacerations, repair/toilet & suture, with/without debridement" href="/patients-visitors/bill-estimator/skin/Pages/skin-and-subcutaneous-tissue-lacerations-deep-more-3cm-multiple-lacerations-repair-toilet-suture.aspx"> SA842S: Skin and Subcutaneous tissue, Lacerations (deep >3cm/multiple) lacerations, repair/toilet & suture, with/without debridement
• SA852S: Skin and Subcutaneous Tissue, Tumor/Cyst/Ulcer/ Scar, Excision Punch/Shave biopsy, Lesion size up to and including 15mm in diameter
• SA853S: Skin and Subcutaneous Tissue, Wound, Debridement <3cm
• SA864S: Skin, Keratoses/Warts/Tags/Similar Lesions, Excision (more than10 lesions)
• SA831S: Skin And Subcutaneous Tissue, Foreign Body (Subcutaneous), Removal
• SA868S: Skin, Scar (Extensive), Revision
• SF700I: Intestine/Stomach, Upper Gl endoscopy with polypectomy/ removal of foreign body/diathermy of bleeding lesions / injection of varices / removal of single polyp - Day Surgery
• SF700I: Intestine/Stomach, Upper Gl endoscopy with polypectomy/ removal of foreign body/diathermy of bleeding lesions / injection of varices / removal of single polyp - Inpatient
• SF701I: Intestine/Stomach, Upper Gl endoscopy with / without biopsy - Day Surgery
• SF701I: Intestine/Stomach, Upper Gl endoscopy with / without biopsy - Inpatient
• SA704R: Radiotherapy, Intracavitary Brachytherapy (Single channel): Endometrium, others
• SI701U: Uterus/cervix, Hysteroscopy, Diagnostic (without Anaesthesia)
• 12 weeks)" href="/patients-visitors/bill-estimator/uterus/Pages/uterus-hysterectomy-MIS-complicated-more-than-12-weeks.aspx"> SI712U: Uterus, Hysterectomy, MIS (Complicated) (>12 weeks)
• SI725U: Uterus/cervix, Hysteroscopy, Diagnostic, D&C
• SI804U: Uterus, Broad Ligament Tumor, Hysterectomy
• 5cm)" href="/patients-visitors/bill-estimator/uterus/Pages/uterus-fibroids-myomectomy-complicated-more-than-5cm.aspx"> SI815U: Uterus, Fibroids, Myomectomy (complicated) (>5cm)
• SI817U: Uterus, Genetic Abnormality, Ultrasound Guided Chorionic Biopsy
• SI818U: Uterus, Genetic Abnormality/Fetal Maturity, with/without Ultrasound Guided Amniocentesis
• SI844U: Uterus, Pregnancy, Complicated Caesarean Section (See Footnote For Definition Of 'Complicated')
• SB745J: Joint, Various Lesions, Joint aspiration/arthrocentesis/injection
• SD707B: Blood Vessels, Subcutaneous Implanted Vascular Port, removal
• SE712L: Lymph node, Various lesions, Imaging Guided Percutaneous Biopsy - Superficial
• SE801M: Marrow, Various Lesions, Diagnostic Aspiration
• SD722V: Vein, Various Lesions, Imaging Guided Peripheral Insertion of Central Catheter (PICC) - Day Surgery
• SD722V: Vein, Various Lesions, Imaging Guided Peripheral Insertion of Central Catheter (PICC) - Inpatient
• 5cm)" href="/patients-visitors/bill-estimator/others/Pages/ovary-tumor-cyst-cystectomy.aspx"> SI802O: Ovary, Tumor/Cyst, Cystectomy (Complicated, >5cm)
• SD713V: Vein, Varicose Veins, Imaging Guided Endovenous Laser Treatment, 1 Leg
• SG800U: Ureter, Calculus, Ureteroscopy And Lithotripsy With/Without Ultrasound

Request for Medical Report

Medical Report Fees All Medical Report requests require upfront payment. We are unable to process medical report requests unless payment has been made.  

Please note that we will process the request only when full payment and the completed application form are received.

Applying for a Medical Report

1.       For Singpass users : Please apply for a medical report via the NUHS app (under "Medical Report Request" module. You may download the OneNUHS App user guide for request medical reports here . Please refer to our cancellation policy prior to making your application.

2.       If you are applying on behalf of your family member (parent/ child), please add them as a dependent and apply under their profile .

3.       Please submit an enquiry using this form if your request meets the following criteria:

a)       You are not a Singpass user

b)      You are applying on behalf of a patient who is unable to provide consent

c)       The medical report is not available on the OneNUHS app

d)      You have a payment enquiry regarding your request

e)       You are seeking a clarification on a previous medical report request

Cancellation Policy There will be no refund provided upon cancellation of investigation results, duplication of medical certificate and discharge summary.

For cancellation of all other reports, an admin fee of one-third the report price will be levied. No cancellation will be allowed once the report has been written by the doctor. Application and Consent Forms for Medical Report Requests made via Email or Front Counter

All medical report requests will require an Application & Consent for Release of Medical Information (Form A) . Please complete this form and attach it to your email request.

Additional consent and declarations may be required for verification purposes:

Payment Methods

We accept NETS, Credit Card, Cheque and Internet and Mobile Payment (including PayNow).

Cheque payments should be made payable to National University Hospital (Singapore) Pte. Ltd. and mailed to:

Medical Records Office National University Hospital 5 Lower Kent Ridge Road Kent Ridge Wing, Level 1 Singapore 119074

To request for a medical report, please take note of the following requirements:

• Patient's written consent is required for the release of medical information
• For patients below 21 years old, the consent of the patient's parent or legal guardian is required.
• If the patient is deceased, a copy of the patient's death certificate must be produced and the consent of the patient's estate is required

Patients can request for medical reports while one is still being warded and before discharge.

A request can be made to any Patient Service Centre or directly with the Medical Records Office if the patient has been discharged.

Mail the completed application form and cheque to: Medical Records Office National University Hospital 5 Lower Kent Ridge Road Kent Ridge Wing, Level 1 Singapore 119074

For cancellation of all other reports, an admin fee of one-third the report price will be levied. No cancellation will be allowed once the report has been written by the doctor.

How much do I need to pay?

Payments may be made by cash, cheque or credit card.

Charges based on the type of medical information/ services required:

Types of Medical Information / Services

Fee (inclusive of GST)

Completion of Detailed Insurance Form It is a detailed insurance claim form to be completed by the doctor. The form will require information such as: diagnosis, details of injuries suffered and treatment provided

Completion of Disability Claim Form It is a detailed insurance claim form provided by the insurance company for the doctor to assess the patient's disability status.

Completion of Diagnosis/Procedure & ICD9 Code on Insurance Form by Medical Records Office It is an insurance form usually requested by insurance company of a Group Department. The form will require information such as the: diagnosis, diagnosis code, procedure performed, procedure code and name of referring doctor.

Ordinary Medical Report It is a report put up by the doctor based on a patient's medical records. It is a factual record of the patient's medical problem.

Specialist Medical Report This is a detailed medical report that usually highlights the history of medical complaint or injury. The doctor will include findings of the assessment as well as his or her opinion and prognosis of the patient. For patients with orthopedic conditions, an appointment will be arranged for the patient to be reviewed by the doctor. For other disciplines, an appointment would only be arranged if the doctor request for it.

Specialist Psychiatrist Report It is a report put up by the psychiatrist based on the patient's medical records. It is a factual record of the patient's psychiatric condition.

Second Opinion Report A medical report requested by a non-NUH patient seeking a second opinion from a NUH specialist. An appointment will be arranged for the specialist to assess the patient. The patient may be required to provide the attending specialist with his or her previous medical report or investigation results.

Investigation Results   Photocopy of investigation results such as x-ray reports, CT scan reports, blood test results, ECG reports, Histopathology reports, Cytogenetic reports, Bone Density Report and Urine Test Result.

S$11.20 per service

Duplication of Medical Certificate It is an application for a certified true copy of medical certificate for hospitalisation/outpatient medical leave issued by NUH doctors.

S$11.20 per certificate

Pathology Slides Pathology blocks are not released. However, request for pathology slides may be made at a fee. Our pathologists will review the request and advise on the number of slides that will be provided.

S$23.40 per slide + S$11.20 processing fee

Therapy Report It is a report put up by a physiotherapist, occupational therapist, speech therapist or podiatrist on a patient's medical records. It is a factual record of the patient's medical problem such as diagnosis, treatment given and performance of the patient based on the last therapy visit/session.

Functional Capacity Evaluation Report It is a comprehensive evaluation carried out by an occupational therapist. It includes an evaluation of an individual's physical, sensory, perceptual, cognitive ability to engage in activities of daily living, work, leisure and life roles activities. The FCE determines an individual's ability to perform the physical demands of a job after a disease, injury or an accident. The occupational therapist will analyse the necessary components of the patient's occupation, to determine if he or she is able to fit in the essential occupation performance components. 

The FCE can be done for the following purposes: - law suit, insurance and workmen compensation claim - to determine if an injured worker has the ability to perform the job or alternate work.

Workmen Compensation Assessment   This is an assessment to determine work-related injuries, the degree and period of disability for workmen's compensation purpose under the Workmen's Compensation Act. Scope of the report is as per "Medical Report on Traumatic Injuries for Workmen's Compensation" form prescribed by the Ministry of Manpower.  Note:  - The "Medical Report on Traumatic Injuries for Workmen's Compensation" form needs to be obtained from the Ministry of Manpower. 

This may involve a review of the patient at the Specialist Outpatient Clinic.

Workmen Compensation Objection Report   This is a referral from the Ministry of Manpower to assess and re-determine work-related injuries, the degree and period of disability when any of the parties (insurer, employer or injured worker) object to the results of the initial workmen's compensation assessment. Scope of the report is as per "Referral of Objection to Permanent Incapacity Under Compensation (Medical Board) Regulations 2005 - Medical Report on Traumatic Injuries for Workmen's Compensation" form prescribed by the Ministry of Manpower.  Note: - The "Referral of Objection to Permanent Incapacity Under Compensation (Medical Board) Regulations 2005 - Medical Report on Traumatic Injuries for Workmen's Compensation" form needs to be obtained from the Ministry of Manpower. 

This may involve a review of the patient at the Specialist Outpatient Clinic.   

Memo Memo is a statement from a doctor to state patient's diagnosis with no explanation of medical condition.

Note: The above charges do not include laboratory charges / x-ray charges / facility fee etc.

How soon can I obtain the requested medical information?

As a general guide, a medical report takes approximately 8 weeks to compile and process. It may take longer if:

• The patient has upcoming clinic appointments or has been warded
• Reports are requested from several clinical departments
• Doctor-in-charge is away

Duplication of investigation result, radiological report and medical certificates are typically available within one week from the date of request received by the Medical Records Office (MRO).

What documents do I need to bring to collect the medical report/insurance form/medical documents?

If you are collecting the medical report/insurance form/medical documents personally at the Medical Records Office, please bring along the following documents for authentication:

• NRIC of patient
• If the patient is unable to collect the documents in person, please complete the  Authorisation Letter  and bring it together with both Identification documents of the patient and authorised individual

Please note there is no self-collection for Workmen Compensation report. The report will be mailed directly to the Ministry Of Manpower.

Why do I need to pay for medical report?

• A Medical Report is a comprehensive summary of the patient's medical condition. The doctor will need to review the patient's medical records in order to produce an accurate report that meets the needs of the requestor.
• Medical Report is not covered under regular consultation and hospitalization fees. Thus, a fee will be charged to cover the hospital's administrative costs for providing the report.

This is a standard practice across all the Public Healthcare Institutions in Singapore.

Who should I contact if I want to check on the status of the request or have further enquiries?

​ You may email or contact our Medical Records Office. For the location and contact details of our Medical Records Office, click  here .

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Application Letter to Submit Medical Certificate

Medical leave letter format for office. Sample letter for a medical leave of absence. Sample letter for leave of absence from work due to illness. Medical leave letter from a doctor. Excuse letter for absence due to illness—medical leave letter for school.

Application to Submit Medical Certificate Lately

I want to submit my medical certification as part of my documents. Unfortunately, it is late, but I was unable to get it timely. Therefore, I request you to please accept my submission. My medical certificate is attached herewith, looking for your kind acceptance.

Sincerely Yours,

Letter to Accept Medical Certificate

To, The principal, Oxford grammar high school, Florida

With due respect, I would like to bring it to your knowledge that I had a serious accident last week, and I cannot attend college for 2 months as my leg is fractured. Therefore, I have submitted a leave application, but I have to submit a proper medical certificate for a long-term leave according to the policy.

I have attached a medical certificate from my doctor with the description. I request you to accept my medical certificate and grant me leaves. I assure you that I will keep myself self-updated regarding the course. I shall be really thankful for this act of kindness. Thanks

James David, 11 th B

Application to Submit Medical Certificate

To principal, James High School, USA

Dear Sir/Madam,

I want to submit my medical certificate to you. For the last one week I was absent due to an accident which I had last Sunday. That’s why I was unable to attend school.

Kindly accept my medical certificate, and count my leaves as medical leaves.

Thank You for your time.

Yours obediently

Alyson Mark

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5 thoughts on “Application Letter to Submit Medical Certificate”

REQUEST LETTER TO LATE SUBMIT MEDICAL CERTIFICATE ,ON JOINING NEW APPOINTMENT(JOB)

Dear Sir, I want to request a delay in the submission of my medical certificate. I know about the deadline for document submission. But obtaining a medical certificate also a time-taking process from your mentioned Medical LAB. I assure you to submit the required Medical Certificate on (date). I hope you understand this delaying issue. Sincerely Yours, (Your Name)

I really need medical certificate for 1 month for school leave

please grant me medical certificate so I can get leave from school for one month I want it please because it is examination in my coaching

Plz someone send me😭

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Application of Medical Report   //

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​​​​​Patient medical information is kept strictly confidential. We respect our patients and the release of their confidential medical information in a form of a medical report requires the consent of the patient as well as discretionary approval of IMH.

Who can request for a patient’s medical report

How to apply for a medical report, documents required, medical report types and fees, assessments by doctor, mailing and collection of medical report, validity of medical report, cancellation of medical report application, contact the medical records office.

• Courts/Law firms
• Insurance firms
• Ministries, Statutory Boards such as Central Provident Fund Board (CPF), Ministry of Social and Family Development (MSF) or other government agencies
• Government authorities such as Singapore Police Force (SPF) and Singapore Armed Forces (SAF)
• Patients (application and purpose will be reviewed by the attending doctor)

All applications must be accompanied by an official letter from the organisation with the patient’s name, NRIC number and the purpose of the application to be included.  

Please send in the medical report application via:

• An email request to the Medical Record Office (MRO) at  [email protected]​
• Hardcopy letter of request by mail
• Clinic B at IMH
• Community Wellness Clinic at Geylang Polyclinic
• Community Wellness Clinic at Queenstown Polyclinic
• Child Guidance Clinic (CGC) at the Health Promotion Board
• An official letter from the organisation with the patient’s name, NRIC number and the purpose for the application must be clearly stated.
• The patient’s written consent to release his/her medical information with a witness’ details and signature. For patients who are below 21 years old, the consent of a parent or legal guardian is required. You may download the IMH Patient Consent Form here ​​ (PDF, 710 KB) or obtain a hardcopy form from IMH Medical Records Office.
• Please attach other relevant documents that are available e.g. medical reports done at other healthcare institutions, previous assessment reports (e.g. psychological and IQ tests).

Payment must be made in full before the medical report will be released to the patient/ requester. For any shortfall of the medical report fee, a top-up is required. If the payment made exceeds the medical report fee, a refund cheque will be processed by Finance Department and sent to the patient/payer within 2 months.

Our doctors will review every medical application and determine the most appropriate type of medical report to be provided.

Common types of medical reports:   

    **Depending on the type of report and complexity of the case, the following are some examples of situations where the medical report may take a longer time to be completed.  

• The patient is hospitalised when the report is being prepared.   
• The doctor is on leave or away for conference.  
• The patient requires further assessment(s) before the doctor can complete the report.  ​

The doctor who is preparing the report may require the patient to undergo other assessments/tests. The medical report fee excludes the additional fees of such tests and the medical report will not be released until full payment is made. 

• Psychological/IQ Assessments
• Laboratory tests
• Medications

Crossed cheques should be made payable to the “Institute of Mental Health” and mailed to:

Institute of Mental Health 10 Buangkok View Singapore 539747 Attn: Medical Records Office

Payment by cash, credit card, NETS can be made in person at IMH Clinic B registration counter. A Medical Records Office staff will assist you. For Paynow or funds transfer via GIRO, please check with us for the bank details.  

For patients who have difficulty paying the fees, a referral will be made to the Medical Social Work team who will assess the patients’ eligibility for financial assistance. Patients will be asked to submit the relevant supporting documents to the medical social worker.​​

The medical report will be mailed to the mailing address as stated in the IMH Patient Consent Form.

For a medical report application by the patient, only the patient is allowed to self-collect the medical report upon producing his/her NRIC for verification. For the collection of medical report by non-patients, the patient’s authorisation letter is required. 

The medical report is valid for 6 months from the report date. A fresh application is required after the medical report expires.  

Please contact us to enquire on the status of the medical report for the cancellation request.

•  An official cancellation request must be made in writing through a letter or an email, indicating the reason for the cancellation.
• An administrative fee of $24 will be charged for the cancellation.
•  A cancellation is not allowed if the doctor has already started writing the report. No refunds will be made.
• If the cancellation is approved, a refund cheque will be processed by IMH Finance Department and sent to the payer within 2 months.

Note: For payments made by the patient, the hospital reserves the right to offset any outstanding bills by the patient before a refund is given. 

Download Request for Medical Report information sheet  h​ere​​  (PDF, 70 KB) .​

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Apply for Medical Report

Why you need a medical report.

A medical report covers a patient’s clinical history, or hospital admission or clinic visit. The doctor will write the report based on medical information available on the patient.

When you make an insurance claim, you may be asked to submit a medical report or Doctor’s Statement (form with set questionnaire provided by the insurance company) as one of the supporting documents.

Most insurance companies and some organisations provide their own medical report form with a set questionnaire. Please check with them before applying for a medical report.

Types of Medical Reports

• **Please obtain forms from the insurance companies or relevant organisations.
• The patient is liable for all additional charges should further tests be required for the preparation of the medical report.
• The fees do not cover consultation, assessment and tests if the patient is required to attend a medical review at the Psychiatric Clinic.
• An administrative charge of one-third of the payment will be imposed if a cancellation request is made while the medical report is being processed.
• Cancellation is not allowed if the doctor has already prepared the report.
• Our institution reserves the right to offset refund, if any, against amount owed by the patient on bills from the same institution or from Yishun Community Hospital and Admiralty Medical Centre.

How to apply for medical report

You may apply for medical reports:

• Apply in person
• Mail request
• Email request
• Apply online via HealthHub portal (for medical report applications only)

Do note that your application will only be processed upon receipt of the correct fee and supporting documents.

Where to submit request for medical report

Applying in person, patient service centre.

Tower A, Level 1

Opening hours

Monday - Friday: 8.30am - 5.30pm Weekend & Public holiday: Closed

Patient Registration Counter at Clinics

Tower D, Level 1

Monday to Friday: 8.30am - 5.30pm Weekend & Public holiday: Closed

Patient Registration Counter

Kampung Admiralty, Level 3 or 4

Monday to Friday: 8.30am - 5.00pm Saturday: 8.30am - 11.00am Sunday & Public holiday: Closed

Submission in Physical Drop Box

You may submit the filled up consent form with supporting documents in a drop box located outside Patient Service Centre, Tower A Level 1 , at Khoo Teck Puat Hospital.

Please use the official consent form, which can be downloaded from this website only.

Applying by Post

Khoo teck puat hospital.

90 Yishun Central Singapore 768828

Attn: Medical Records Office

Yishun Community Hospital

2 Yishun Central 2 Singapore 768024

Admiralty Medical Centre

Block 676 Woodlands Drive 71 #03-01 Kampung Admiralty Singapore 730676

What is required to apply for medical report

• Patient’s signed consent is needed to release his / her medical information. Please complete the Application & Consent for Release of Medical Information - Form A (PDF, 259KB) . For more information, please refer to the section below on Consent & Application Procedure .
• Copy of patient’s NRIC / identification document (front and back).
• Questionnaire form from insurance company or relevant organisations, if applicable.
• Cheque payment is required for requests by mail.

Please write patient’s name, NRIC/ Fin number and contact number on the back of the cheque.

When will medical report be ready

We will process the application once we have received and verified all the required forms, supporting documents and payment.

How to receive the medical report

Consent & application procedure.

In accordance with the Personal Data Protection Act (PDPA), application for medical report can only be made by the patient, with the following EXCEPTIONS:

• under the age of 21 years
• mentally incapacitated
• If the report is for Work Injury Compensation, application may be made by the employer. The report will be sent directly to the Ministry of Manpower.
• If the patient is a foreign worker who has left Singapore, application may be made by the employer. The purpose is solely for insurance claim, to reimburse the medical bills incurred by the patient.

To Contact Medical Records Office

Frequently asked questions.

What is a Doctor’s Statement or Attending Physician’s Statement?

This is a medical report set in a form format, provided by an insurance company to be completed by the doctor who attended to the insured person for his/her illness.

If I have been seen by two different doctors in Khoo Teck Puat Hospital, can I request for one consolidated medical report?

The two doctors you had visited were for two different reasons. It is necessary for each doctor to write the medical report based on your medical condition and the treatment given. Hence, you need to request for two separate medical reports.

I have visited the hospital for various reasons. Which medical report should I be requesting?

There is a fee for each report. You are advised to request for the report that is relevant for the purpose of your claim.

Can I use MediSave or MediFund to pay for the medical report?

No. MediSave and MediFund cannot be used.

What supporting document can the hospital provide me for my outpatient visit / hospitalisation claim?

You may request for:

• Visit Summary - for A&E visit and 23hr stay
• Referral Letter - in which you are referred to Khoo Teck Puat Hospital
• Inpatient Discharge Summary – for admission
• Patient Report – for day surgery or endoscopy procedure

Please request for the required document on the day of appointment or discharge.

Can my insurance company request for a copy of my medical records (Inpatient Discharge Summary)?

Yes. The appointed insurance company must submit an official letter with your signed consent and copy of your NRIC, if available.

Why must I pay for a medical report?

The doctor needs to review the patient’s full medical records to prepare the report with the information as required. This is not done during the patient’s outpatient visit or hospital stay. Hence, the outpatient consultation fee or hospitalisation bill does not include the cost of medical reports. The fee levied for providing the medical report covers the hospital’s administrative costs and the doctor’s professional input.

Can I view my own medical record and medication list?

You may access some of your clinical records at the HealthHub portal .

At present, patients may view their records, which include:

• Immunisations
• Laboratory test results
• Screening records
• Discharge information
• Vital health tracking
• Appointment information
• Medications

 Forms Download

• Application & Consent For Release of Medical Information - Form A (PDF, 259KB)
• Additional Consent For Release of Medical Information - Form B (PDF, 212KB)
• Release of Medical Information of Foreign Workers to Employers (Indemnity) - Form C (PDF, 83KB)
• Authorisation for Collection of Medical Report (PDF, 91KB) ​

 Online Application

Request for Discharge Summary (SingPass required)

Medical Report

Remember that all kinds of organizations make use of reports. Hospitals and other medical institutions are no exceptions. Rather than deal with things like sales reports and the like, those organizations are responsible for creating a medical report. Are you curious enough to try and learn more? No problem. Scroll on and we’ll not only provide information that’s about medical reports, but you’ll also come across examples of what an excellent medical report template looks like.

Medical Report Template

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What Is a Medical Report?

From the name itself, a medical report is a written report that usually contains the results of a medical examination conducted on a patient. It describes or outlines the findings of a medical professional, along with any suggestions for the patient’s treatment and recovery. Also referred to as a medical report letter, there’s lots more to learn about this, including how to write a medical report letter, which we will be tackling shortly.

Tips for Creating a Medical Report from Scratch

Moving on, we will now discuss the varied creation process of medical reports. Those eager to learn how to write a medical report will also be happy to know that there’s no need for strict steps or adhering to any formal medical report form. To create a medical report, all one has to do is follow the following steps:

Tip 1: Make it Comprehensive

A medical report that comes off as vague is practically useless. For it to be valid and useful, the medical  professional writing it must go into detail. With that said, use specific terms and provide particular comments and suggestions for the benefit of the report’s recipient.

Tip 2: Provide a Chronological Timeline

Sometimes, it is necessary to draw up a timeline of the patient’s symptoms. Doing so will help guide other professionals who may be assisting the patient with his or her treatment. When writing up a timeline, stick to chronological order and make it as easy to understand as possible.

Tip 3: Avoid Too Much Jargon

Since a medical report is meant for the benefit of the patient, it pays not to utilize too much vague medical jargon . Use professional language and ensure that there is enough clarity to prevent any misunderstandings among all of the involved parties.

Tip 4: Keep a Personal Copy

The creation of a medical report may dictate that you keep a separate but identical copy for yourself. The purpose of doing so is purely related to documentation . Also, in the event that the original medical report is somehow lost or tampered with, the patient can always turn back to you for references.

What are common inclusions in a medical report?

Besides the patient’s personal data, there are also multiple kinds of information written into these reports. Among the numerous inclusions would be: possible allergies, vaccinations, current medical evaluation , health issues, family or personal medical history, and more.

What are the different kinds of medical reports?

For some of the more in-depth and extensive examples, the different kinds of medical reports often include radiology reports, printable laboratory reports , and pathology reports.

How does a medical report differ from a prescription?

A medical report tends to be all-encompassing, complete with details of a patient’s illness and even prescriptions. If you’re just talking about prescriptions as a stand-alone document, then the details are much sparser, with only the doctor’s prescribed treatments and some of the patient’s personal  details written on it.

Considering how complicated a  hospital’s daily operations can be, there was already an idea of how nuanced medical reports are. With that said, there’s just as many kinds of information out there that you may not have realized before. It is our hope that we were able to cover as much of it, such as the tidbits about how to write a medical report for a patient. Having reached the end of this article, we implore you to choose carefully regarding how you will use your new-found knowledge. Decide with wisdom and act as soon as you can!

Report Generator

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Prepare a report analyzing the trends in student participation in sports and arts programs over the last five years at your school.

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Medical Report Form

A medical report form is a document used by medical professionals for documenting a patient’s medical treatment. With Jotform’s free Medical Report Form template, you can collect information from patients instantly by embedding the form in your website — and the form can be filled out using a computer or tablet at your office, or using a mobile device at home.

Just customize the Medical Report Form to match your practice — add your logo and colors, and easily add more form fields. As well as customizing fields and questions to match your needs, you can also update the design of this template. Jotform is a fully customized, easy-to-use Form Builder that includes changing, adding, or removing fields through the drag and drop function, and changing the colors, fonts, and background without any coding required. Easily embed this form either on your website or share it via URL. With Jotform’s 100+ integrations, you can also store and analyze your Medical Report Form submissions with Google Drive. All can be achieved without coding!

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Screening Checklist For Visitors And Employees

A screening checklist for visitors and employees is used to track the contact details and symptoms of every visitor or employee who has entered an establishment during the coronavirus crisis. Whether you work for a hospital, doctor’s office, or other essential organization that needs to stay open, reduce the spread of COVID-19 by running checks on visitors and employees using our free online Screening Checklist for Visitors and Employees — easy to fill in on any device. By keeping track of the symptoms of everyone who enters your building, you can take steps to prevent the coronavirus from spreading.This online form already has fields for names, symptoms, and temperature checks, but use our drag-and-drop Form Builder to add other fields that are essential for your needs. Add your company logo, rearrange the layout, or include an e-signature field to let people officially sign off on their coronavirus checks. If you need to transfer the information to your other accounts — such as Salesforce (also available on Salesforce AppExchange), HubSpot, Zoho, Airtable, Trello, Slack, and more — use our free form integrations to do it automatically. And you can even protect submissions with sensitive health information using Jotform’s HIPAA compliance option. Keep everyone safe and reduce the spread of the coronavirus with a free Screening Checklist for Visitors and Employees.

Patient Feedback Form

A patient feedback form is a survey with questions that allows medical doctors to gather feedback from patients regarding their overall experience with the clinic. Get patient feedback with this online feedback form and improve your service. Want to start from scratch? Get started with the Jotform's easy-to-use Survey Creator now! Whether you’re a medical professional or you’re with a patient’s medical practice, use this free Patient Feedback Form template to gather customer feedback online! Just customize the questions in this Patient Feedback Form to match your practice, embed the form on your website, or share it with a link, and get results quickly. Boost your business or patient satisfaction through this free service!Being the owner of your own practice is an incredible feeling, but it’s also tough to juggle the variety of tasks involved. Luckily, Jotform’s 100+ integrations can help with that! You can sync form submissions with your storage service of choice, give you more time to spend with your clientele. You can also use our incredibly powerful Form Builder App to customize the form according to how you want to get feedbacks from your patients. With Jotform’s free online Patient Feedback Form, you can collect information from patients that you might not have been able to before.

Patient Medical History Form

The Patient Medical History Form template is used by patients to register clinical history through providing their personal and contact information, weight, drug allergies, illnesses, operations, healthy habits, unhealthy habits. You can integrate the data to your own system and track your records. You can use this template as your basis and create your own form adding your logo, more questions, add more widgets and either embed it t your site or use it as a standalone form.

These templates are suggested forms only. Before using this or any form as a contract or other legal document, please consult with an attorney to make sure it meets the legal needs or your situation. Do not use this form to send a legal request to Jotform.

• Form Templates /
• Healthcare Forms /
• Medical Surveys & Questionnaires /

Medical Surveys & Questionnaires

A medical report form is a document used by medical professionals for documenting a patient’s medical treatment.

Prevent the spread of COVID-19 with a free Screening Checklist for Visitors and Employees. Ideal for hospitals or other organizations staying open during the crisis.

A patient feedback form is a survey with questions that allows medical doctors to gather feedback from patients regarding their overall experience with the clinic.

The template is used by patients to register medical history through providing their personal information, weight, allergies, illnesses, operations, healthy habits, unhealthy habits. You can integrate the data to your own systems.

Coronavirus Case Report Template

People can report suspected cases of COVID-19 in their workplace or community. Easy to customize, integrate, and share online. No coding required.

Gym Health Questionnaire Form

A gym health questionnaire is a health form that is used by gym instructors to track the health and fitness of their clients.

COVID 19 Vaccine Survey

Get to know how people feel about the new COVID-19 vaccine with a custom online survey. Easy to personalize, embed, and share. Option for HIPAA friendly features.

Initial Visit Patient Forms (MDR)

An initial visit patient form is used by medical practitioners to collect information from patients as they arrive at their practice's office for an initial visit.

Contact Tracing Form

Reduce the spread of coronavirus with a free online Contact Tracing Form. Ideal for hospitals, medical organizations, and nonprofits. Collect data on any device.

Medical Questionnaire

Determine if clients are healthy enough to take part in your activity with a free online Medical Questionnaire. Fill in on any device. Sync with 130+ apps.

Medical Employment Information Form

Here is an Employee Medical History Form that can be used to create an employee medical information database which provides employee contact information along with emergency contact information and medical insurance details.

Counseling Intake Form

The Counseling Intake Form allows for an easier client registration process as it automates gathering information from your clients, reduces paperwork and helps to keep patient records in a systematic way.

Health Evaluation Form

If you have an online health service , this forms is suitable for you. Get your patient history, lifestyle and more. Customize it to your needs

COVID 19 Questionnaire

Record information about families in need. Free questionnaire for nonprofits. Easy to customize and embed. Integrate with 100+ apps. No coding required.

Patient Health Questionnaire

If you have an online health service , this forms is suitable for you. Get your patient to fill the form so that you can be able to diagnose them.

Health Survey

A Health Survey is a form template designed to collect medical information from patients and log their anamnesis

Covid Contact Tracing Form Template

A COVID-19 contact tracing register is used by medical organizations to identify people who have come into contact with a person who is infected with COVID-19, to help prevent the disease from spreading.

HIPAA Medical History Form

HIPAA Medical History Form allows gathering patient's contact details with their current symptoms, medications, allergies, drug use, and family medical history that allows for a better healthcare service and management process.

BMI Calculator

Here is a BMI Calculator which collects submitter name, age, gender information with their height and weight measurements and provides them with their body measurement index and body type information.

Nutritional Assessment Questionnaire Form

Here is a Nutritional Assessment Questionnaire that is useful for health institutions to learn more about patients' eating habits by asking their blood sugar, fatty acid, inflammation, toxicity, and eating habits.

Alternative Medicine Patient Intake Form

Do you work for alternative medicine? This alternative medicine disclaimer form is very useful for those herbal medicine practitioners, wellness practitioners, alternative medicine practitioners, holistic medicine practitioners, etc.

Veterinary EMR

Do you work for the veterinary group? This veterinary physical exam template is based on the SOAP template for a veterinary physical exam and evaluation. Veterinary treatment sheet template collects information about client's contact details, appointment time, client pet's details and client physical exam findings.

Patient Intake Form

Register new patients for your practice with a free online Patient Intake Form. Great for telemedicine or telehealth. Option for HIPAA friendly features.

SPEECH/LANGUAGE PATHOLOGY PROGRESS NOTE

Here is a simple speech therapy progress notes template made for language therapists and healthcare provider/practitioners. This sample speech therapy progress notes will allow you to gather all the necessary information to keep the progress of your patients. By using this form template, you can also schedule appointments and make bookings for your patients.

About Medical Surveys & Questionnaires

As a medical institution, you might be super confident in your personnel's professional abilities. However, as for any businesses who deals with paying customers, it’s absolutely necessary to get feedback, regarding both medical staff and the institution itself. Jotform’s surveys and questionnaires provide this chance. Since they are completely customizable, you can edit them to match your needs as well.

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Medical Applications and Forms

Medical examinations.

The expiration date on the Medical Examination Report Form, MCSA-5875, Medical Examiner's Certificate, MCSA-5876, Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870, and the Vision Evaluation Report, Form MCSA–5871 has been updated to 12/31/2024, and all forms are posted below.  Please note that the only change to the forms is the change in the OMB expiration date from 11/30/2021 to 12/31/2024. 

Medical Examiners should start using the forms with the 12/31/2024 date as soon as possible.  However, MEs that have purchased these forms in bulk, or require time to reprogram electronic system forms, may continue to use the old forms until stocks have been depleted or forms have been reprogrammed but should transition to use of the new forms as quickly as possible.  Based on this guidance, SDLAs are encouraged to continue to accept these forms.

Until December 22, 2015 , Certified Medical Examiners are required to continue to use current driver examination forms found below.

• Medical Examination Report for Commercial Driver Fitness Determination
• Medical Examiner's Certificate
• Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870
• Vision Evaluation Report, Form MCSA–5871
• Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872 (optional)
• Medical Examination Report (MER) Form, MCSA-5875
• Medical Examiner's Certificate (MEC), Form MCSA-5876
• 391.41 CMV Driver Medication Form, MCSA-5895 (optional)

USE OF THE NEW FORMS PRIOR TO DECEMBER 22, 2015 IS PROHIBITED.

Medical Exemptions

Diabetes package.

This package has been removed due to the update of the Diabetes Standard. For more information please visit the New Diabetes Standard Overview Webinar .

Vision Package

This package has been removed due to the update of the Vision Standard. For more information please visit the New Vision Standard Overview Webinar .

Hearing Package

• Federal Hearing Exemption Application (NEW)
• Federal Hearing Exemption Application (RENEWAL)
• Medical Release Form (Hearing) SAMPLE
• Medical Release Form

Seizure Package

• Federal Seizure Exemption Application (NEW)
• Federal Seizure Exemption Application (RENEWAL)
• Medical Release Form (Seizure) SAMPLE

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