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Rev. 6/19
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M20UP-045
Rev. 6/24
Request for External Records
Place Patient Label Here
Duke University Hospital
Duke Raleigh Hospital,
a campus of Duke University Hospital
Duke Eye Center,
a department of Duke University Hospital
Raleigh Ambulatory Surgery Center,
a campus of Duke University Hospital
Duke Ambulatory Surgery Center,
a campus of Duke University Hospital
Duke
Regional Hospital
Duke Healt
h Integrated Practice
Duke Primary Care
Arringdon Ambul
atory Surgery Center
Davis Ambulatory Surgery Center
Other (Please specify):
__________________________
THIS FORM SHOULD ONLY BE USED WHEN REQUESTING HEALTH INFORMATION FROM AN OUTSIDE
HEALTH CARE PROVIDER FOR CONTINUITY OF CARE
REQUEST FOR EXTERNAL RECORDS
PART A: PATIENT INFORMATION
Patient Name: Phone: Email:
Address:
Date of Birth: SS# (last 4 digits): Duke Health Medical Record #:
PART B: REQUESTING INFORMATION FROM
Outside Health Care Provider
Name: Phone: Email:
Address: Fax:
PART C: SENDING INFORMATION TO
Duke Health Provider
Name: Phone: Email:
Address: Fax:
PART D: INFORMATION TO BE RELEASED (check all that apply)
Records orInf
ormation:
Abstract/Summary
(Discharge Summary,
Operative/Procedure
Notes, Pathology,
Laboratory, ED Notes,
Clinic Visits, Consults)
Discharge Summary
History and Physical
Consultation Report
Operative Report
Laboratory Reports
Pathology Reports
Radiology Reports
Radiology Images
Physical/Occupational Therapy
Immunization Record
Emergency Department Record
Clinic Visit (Specify
Provider/Clinic)
Other (please specify)
Entire Record
Billing Records
Treatment Date(s):
From to (please be specific) All Treatment Dates
PART E: REVIEW AND APPROVAL
The purpose of this release is for continuity of care, unless otherwise noted:
I understand that the information to be released may include reference to sensitive information related to mental and behavioral
health, genetic testing, HIV/AIDS or other communicable diseases, and drug or alcohol abuse. I specifically approve the release
of the following information that has been marked as sensitive and/or restricted (check all that apply):
Mental and Behavioral Health Substance Use Disorder Genetic Testing
This Form will automatically expire one year from the date signed below unless revoked or another date or event is
written here:
Patient or Duke Health Representative Signature Printed Name Date
PART F: REPRESENTATIVE (complete if signed by personal or authorized representative)
Representative Full Name (please print) Relationship to Patient Phone Number
If you are not the patient, parent of a minor patient, or a Duke Health representative you MUST attach documentation
showing your authority to act on behalf of the patient (Power of Attorney, Court Order, Legal Guardian
Documentation, Executor/Administrator Documentation)
