About this template
The Transfer of Medical Records Form is an essential administrative tool used by healthcare providers, clinics, and patients to authorize and request the secure transfer of protected health information (PHI) from one medical facility to another. Whether a patient is switching primary care physicians, consulting a new specialist, or moving out of the area, this form ensures all necessary permissions and routing details are accurately captured.
Built for modern medical practices, this template streamlines the record-sharing process by collecting critical patient identifiers, current and receiving provider details, specific dates of service, and the exact types of records needed—such as laboratory results, imaging reports, or complete clinical histories. Utilizing Doc2Form enables clinics to instantly generate this structured digital intake form without manual setup, eliminating paper clutter, reducing administrative overhead, and ensuring staff have all necessary authorization details immediately upon submission.
By replacing outdated paper release forms with a streamlined digital workflow, medical offices can improve turnaround times for record requests while maintaining clear, organized digital logs of every patient authorization received.
Key features
- Capture complete patient demographic and identification details instantly.
- Specify exact date ranges and types of medical records to be transferred.
- Collect detailed information for both sending and receiving healthcare facilities.
- Include built-in patient consent and digital signature authorization.
- Organize and review all transfer requests directly within Google Drive and Sheets.
Use cases
Patients transitioning to a new primary care physician or medical spe…
Patients transitioning to a new primary care physician or medical specialist.
Hospitals and clinics requesting historical patient charts from exter…
Hospitals and clinics requesting historical patient charts from external providers.
Insurance and legal representatives requesting authorized medical doc…
Insurance and legal representatives requesting authorized medical documentation.
Specialty clinics coordinating multi-facility patient treatments.
What this form collects
- Patient Full Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Enter your date of birth (MM/DD/YYYY).
- Current Address (Paragraph)Enter your street address, city, state, and ZIP code.
- Phone Number (Short answer)Enter the best phone number to reach you regarding this request.
- Email Address (Short answer)Enter your primary email address.
- Current Facility or Doctor Name (Short answer)Name of the hospital, clinic, or physician holding your records.
- Current Facility Address (Paragraph)Street address, city, state, and ZIP code of the current provider.
- Current Facility Phone Number (Short answer)Phone number for the sending facility's records or medical records department.
- Current Facility Email (Short answer)Email address for the sending facility, if known.
- Receiving Facility or Doctor Name (Short answer)Name of the physician, clinic, or hospital receiving your records.
- Receiving Facility Address (Paragraph)Street address, city, state, and ZIP code of the destination provider.
- Receiving Facility Phone Number (Short answer)Contact phone number for the receiving provider.
- Receiving Facility Email (Short answer)Secure email or fax destination for record transmission.
- Reason for Transfer (Paragraph)Briefly explain why you are requesting this medical record transfer.
- Records to Be Transferred (Checkboxes)Select all types of medical records you wish to include in this transfer.
- Preferred Method of Transfer (Multiple choice)Select how you would like the records delivered to the receiving facility.
- Additional Instructions or Comments (Paragraph)Provide any specific dates of service or special instructions for this request.
- Attach Signed Authorization Document (Paragraph)Please paste a link to your signed authorization document (Google Drive, Dropbox, etc.) or describe the document you wish to attach.
- Consent Date (Date)Enter today's date to confirm your authorization.
- Patient Electronic Signature (Short answer)Type your full legal name to serve as your electronic signature authorizing this transfer.
FAQ
How does Doc2Form help me use this template?
Doc2Form instantly converts documents and structured templates into fully editable Google Forms, allowing you to start collecting patient record requests in seconds without manual building.
Can I customize the list of records that can be transferred?
Yes! Once the template is in your Google Drive, you can fully edit, add, or remove any checkbox options to match your clinic's specific documentation categories.
Is patient data secure with Google Forms?
Google Forms encrypts data in transit and at rest. However, ensure your overall Google Workspace configuration complies with your local healthcare privacy regulations (such as HIPAA or GDPR) before collecting sensitive protected health information.
How do I collect the patient's signature?
This template includes a text field for the patient's legal name and date of consent to serve as an electronic acknowledgment, which can be supplemented with an attached signed authorization document if required by your practice.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.