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Request Form

Patient medical record request form

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

Thanking you,
Yours truly

Instructions

  • 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.

No objection letter

hereby giving my consent to collect my Medical Records.

Thanking you,
Yours sincerely

  • 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.