Medical records request form: log every request in one place

Records requests arrive by phone, post and half-written email. Each one needs the same facts. I would rather give people one link that asks for all of them, so no request starts with a question back.

Use this when

Patients ask for copies before a move, a second opinion or a claim.
A parent or a representative asks on someone's behalf.
You want every request in a single list with a date on it.

Skip it when

You need to verify identity or receive documents here. The form does neither, so keep that step in your own system.
You need a legally exact release. Have a professional check any wording with legal weight.

What is asked and why

Name and birth date let you find the right chart. The role question shows if someone else is asking. Record types and a date range keep the request narrow. Delivery method tells you where to send them. A consent box and a typed name show the person claims the right to ask.

What the AI would ask

"Who is the request for?" Then "Which records do you need?" Then "How would you like to receive them?" It shows the answers and sends only after a yes. See agent-fillable forms.

Check your local privacy rules before collecting health data. This is a form, not medical advice. It pairs with a medical history form and a referral form. More in forms for clinics.

Questions

Does the form send the records back?

No. It collects the request only. You read each row, check the person against your own system, and send the records through the channel your clinic already uses.

Is a typed name a valid signature?

The form pairs a consent box with a typed full name. It is not an e-signature service. Ask a professional whether that is enough for your records policy.

How do I track which requests are done?

Download the responses as CSV and add a status column in your spreadsheet. Sort by the submission time so the oldest request stays at the top.

Or paste the JSON

Give this to your AI. It needs the AI Form API MCP server or an API key. It makes the form and sends you the link.

text

Create this form with the AI Form API create_form tool (or POST https://aiformapi.com/v1/forms with my API key). Then reply with the public_url.

{
  "title": "Request a copy of medical records",
  "description": "Tell us which records you need and how you would like to get them. We will contact you if we need anything else.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Patient's full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "patient_dob",
      "label": "Patient's date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "requester_role",
      "label": "Who is asking?",
      "type": "single_choice",
      "required": true,
      "options": [
        "I am the patient",
        "I am the parent or guardian",
        "I act for the patient with their consent",
        "A new provider asks for the patient"
      ]
    },
    {
      "id": "requester_name",
      "label": "Your name, if you are not the patient",
      "type": "short_text",
      "max_length": 150
    },
    {
      "id": "reply_email",
      "label": "Email for questions about this request",
      "type": "email",
      "required": true
    },
    {
      "id": "reply_phone",
      "label": "Phone",
      "type": "phone"
    },
    {
      "id": "records_wanted",
      "label": "Which records do you need?",
      "type": "multi_choice",
      "required": true,
      "options": [
        "Visit notes",
        "Lab and test results",
        "Imaging reports",
        "Vaccination record",
        "Medicine list",
        "Referral letters",
        "Hospital discharge summaries"
      ],
      "min": 1
    },
    {
      "id": "records_from",
      "label": "Records from this date",
      "type": "date"
    },
    {
      "id": "records_to",
      "label": "Records up to this date",
      "type": "date"
    },
    {
      "id": "request_reason",
      "label": "Why do you need them?",
      "type": "single_choice",
      "options": [
        "Second opinion",
        "Moving to a new provider",
        "Insurance or a claim",
        "A personal copy",
        "Another reason"
      ]
    },
    {
      "id": "delivery_method",
      "label": "How would you like to receive them?",
      "type": "single_choice",
      "required": true,
      "options": [
        "Secure link sent by the clinic",
        "Collect in person",
        "Send to another provider",
        "Postal copy"
      ]
    },
    {
      "id": "send_to_provider",
      "label": "Name and address of the provider to send them to",
      "type": "long_text",
      "max_length": 500
    },
    {
      "id": "release_consent",
      "label": "I confirm I am entitled to ask for these records",
      "type": "checkbox",
      "required": true
    },
    {
      "id": "typed_signature",
      "label": "Type your full name as your signature",
      "type": "short_text",
      "required": true,
      "max_length": 150
    }
  ]
}

Or call the API

bash

curl -X POST https://aiformapi.com/v1/forms \
  -H "Authorization: Bearer $AIFORMAPI_KEY" \
  -H "Content-Type: application/json" \
  -d '{"title":"Request a copy of medical records","description":"Tell us which records you need and how you would like to get them. We will contact you if we need anything else.","fields":[{"id":"patient_name","label":"Patient'\''s full name","type":"short_text","required":true,"max_length":150},{"id":"patient_dob","label":"Patient'\''s date of birth","type":"date","required":true},{"id":"requester_role","label":"Who is asking?","type":"single_choice","required":true,"options":["I am the patient","I am the parent or guardian","I act for the patient with their consent","A new provider asks for the patient"]},{"id":"requester_name","label":"Your name, if you are not the patient","type":"short_text","max_length":150},{"id":"reply_email","label":"Email for questions about this request","type":"email","required":true},{"id":"reply_phone","label":"Phone","type":"phone"},{"id":"records_wanted","label":"Which records do you need?","type":"multi_choice","required":true,"options":["Visit notes","Lab and test results","Imaging reports","Vaccination record","Medicine list","Referral letters","Hospital discharge summaries"],"min":1},{"id":"records_from","label":"Records from this date","type":"date"},{"id":"records_to","label":"Records up to this date","type":"date"},{"id":"request_reason","label":"Why do you need them?","type":"single_choice","options":["Second opinion","Moving to a new provider","Insurance or a claim","A personal copy","Another reason"]},{"id":"delivery_method","label":"How would you like to receive them?","type":"single_choice","required":true,"options":["Secure link sent by the clinic","Collect in person","Send to another provider","Postal copy"]},{"id":"send_to_provider","label":"Name and address of the provider to send them to","type":"long_text","max_length":500},{"id":"release_consent","label":"I confirm I am entitled to ask for these records","type":"checkbox","required":true},{"id":"typed_signature","label":"Type your full name as your signature","type":"short_text","required":true,"max_length":150}]}'

JSON definition

json

{
  "title": "Request a copy of medical records",
  "description": "Tell us which records you need and how you would like to get them. We will contact you if we need anything else.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Patient's full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "patient_dob",
      "label": "Patient's date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "requester_role",
      "label": "Who is asking?",
      "type": "single_choice",
      "required": true,
      "options": [
        "I am the patient",
        "I am the parent or guardian",
        "I act for the patient with their consent",
        "A new provider asks for the patient"
      ]
    },
    {
      "id": "requester_name",
      "label": "Your name, if you are not the patient",
      "type": "short_text",
      "max_length": 150
    },
    {
      "id": "reply_email",
      "label": "Email for questions about this request",
      "type": "email",
      "required": true
    },
    {
      "id": "reply_phone",
      "label": "Phone",
      "type": "phone"
    },
    {
      "id": "records_wanted",
      "label": "Which records do you need?",
      "type": "multi_choice",
      "required": true,
      "options": [
        "Visit notes",
        "Lab and test results",
        "Imaging reports",
        "Vaccination record",
        "Medicine list",
        "Referral letters",
        "Hospital discharge summaries"
      ],
      "min": 1
    },
    {
      "id": "records_from",
      "label": "Records from this date",
      "type": "date"
    },
    {
      "id": "records_to",
      "label": "Records up to this date",
      "type": "date"
    },
    {
      "id": "request_reason",
      "label": "Why do you need them?",
      "type": "single_choice",
      "options": [
        "Second opinion",
        "Moving to a new provider",
        "Insurance or a claim",
        "A personal copy",
        "Another reason"
      ]
    },
    {
      "id": "delivery_method",
      "label": "How would you like to receive them?",
      "type": "single_choice",
      "required": true,
      "options": [
        "Secure link sent by the clinic",
        "Collect in person",
        "Send to another provider",
        "Postal copy"
      ]
    },
    {
      "id": "send_to_provider",
      "label": "Name and address of the provider to send them to",
      "type": "long_text",
      "max_length": 500
    },
    {
      "id": "release_consent",
      "label": "I confirm I am entitled to ask for these records",
      "type": "checkbox",
      "required": true
    },
    {
      "id": "typed_signature",
      "label": "Type your full name as your signature",
      "type": "short_text",
      "required": true,
      "max_length": 150
    }
  ]
}

A medical records request form for your front desk