Get Medical Record Number Request - Grady Health

Filling out the Medical Record Number Request form is an essential step in accessing your medical records. This guide provides clear instructions on how to complete the form effectively online, ensuring you can efficiently meet your needs.

Follow the steps to complete your Medical Record Number Request online.

1. Press the ‘Get Form’ button to obtain the Medical Record Number Request form and open it in your preferred editing tool.
2. Begin by entering the request date in the designated field. Ensure you provide the current date when submitting the request.
3. Fill in the IRB# (Institutional Review Board Number) if applicable. This number helps track the research-related aspects of your request.
4. Enter the ROC (Research Oversight Committee) expiration date, if required, to indicate the validity of your request.
5. Provide the patient’s legal name in the corresponding field. This name should match legal documents for identification purposes.
6. Input the patient's preferred name if different from the legal name. This helps ensure that records are referred to accurately.
7. Indicate the date of birth of the patient, using the format required by the form. This serves as a key identifier for the individual.
8. If applicable, enter the last four digits of the patient’s Social Security Number to assist with unique identification.
9. Select the gender of the patient by checking the appropriate box for 'Male' or 'Female'.
10. Complete the address section, including street address, city, state, and zip code, to ensure accurate correspondence.
11. Provide a current phone number where you can be reached for any follow-up related to your request.
12. Once all fields are completed, review your responses to ensure accuracy. Then, submit the completed form to research@gmh.edu for processing. Remember to allow 48 hours from submission for an update.

Complete your Medical Record Number Request online today to access your records efficiently.