MEDICAL-RECORDS TRANSFER CHECKLIST
Use locally to track a request and confirm that the recipient can use it. Keep this sheet private because it may identify healthcare visits. This is an organizational aid, not a legal request form.

Receiving clinician / office and appointment date:
Records requested by that clinician:
Original holder / records-office contact:
Requested documents and date range:
Imaging: scan type, body area, study date; images AND report needed?
Format and transfer route accepted by recipient:
Identity verification / request form completed:
Expected processing time and quoted charge, if any:
Request date and reference:

ON RECEIPT
Correct name, dates and complete documents checked:
Missing item or apparent discrepancy:
Correction / amendment request reference, if needed:
Originals stored in:

TRANSFER CONFIRMATION
Sent date and approved destination:
Report received and readable (confirmed by):
Images received and accessible (confirmed by):
Remaining action, owner and due date:

Yenra | Updated September 11, 2026
Guide and source context: https://yenra.com/medical-records/
Keep completed copies private. This website does not collect your information.