Medical Record Requisition | Patient Medical Record Request Form

Patient medical record request form

Date* :

Name of the Patient :

UHID* :

Contact No :

Address*:

Date of Admission* :

Date of Discharge :

Dear Sir/ Madam, I request you to please issue photo copies of my / my Patient’s medical records as I need them only for

Purpose :

Thanking you,
Yours truly

Name of Patient/Applicant* :

Re-enter name of Patient/Applicant :

Contact No :

The Indoor Case Papers will be handed over only to the patient / Authorized person between 10 am to 04 pm except Sundays and Public holidays.
Indoor case papers to be collected within one month from date of requisition.
Kindly Contact on +912239666727 or mrd.rhnm@reliancehospitals .com for ant query/ confirmation.
Kindly attach ID proof (Aadhar card/ Pan Card/ Driving license) with the requisition.
In case the insurance company representative requests for ICP, Kindly provide company ID proof will be required along with an authority letter email from the patient.
In case the application is made by anyone other than patient or next to the kin, No objection letter to be submitted to MRD at the time of request/collection.

Date* :

I Mr/Mrs :

UHID* :

Date of Admission :

Date of Discharge* :

Authorize Mr/Mrs :

Relation* :

hereby giving my consent to collect my Medical Records.

Thanking you,
Yours sincerely

Patient Name* :

Re-enter Name of the Patient :

Authorized Person's Name :

Re-enter Name of Authorized Person's :

While Collecting ICP Xerox please bring ID proof of the patient as well as Authorized person with self attested.
Kindly Contact 02239666727 or mrd.rhnm@reliancehospitals.com for any query/ confirmation.