LIFE’S CHECKLISTS · FREE WORKSHEET
Health record request tracker
Organize administrative questions and next actions. Keep identity numbers, clinical records and children’s identifying information in the responsible organization’s secure process. This is a planning worksheet, not an official application or authorization.
First read the completed example. Then write your own answers in the blank sections. If you do not know an answer, write what you need to ask. Official applications may require their own forms.
Completed example
This is a fictional practice entry. Write your own details in the blank sections below.
- Receiving office
- New campus clinic
- Records requested
- Immunization record
- Official request route
- Previous clinic's patient portal request
- Permission required
- Clinic says signed release required
- Receipt reference
- Request receipt saved in private folder
- Follow-up date
- October 30; ask whether records arrived
Date: ____________________
Item 1
Records requested
Official request route
Permission required
Receipt reference
Follow-up date
Item 2
Records requested
Official request route
Permission required
Receipt reference
Follow-up date
Item 3
Records requested
Official request route
Permission required
Receipt reference
Follow-up date
Item 4
Records requested
Official request route
Permission required
Receipt reference
Follow-up date
Notes: