How to Request a Form Completion

Requesting Form Completion

You can easily request a school, camp, or disability form with ChartRequest.

Begin by logging into the Patient Hub. When you’re on the dashboard, click on “Forms.” 

Selecting a Provider

This brings you to the step where you can select the healthcare provider from whom you’re requesting a form. 

If you’ve saved any providers to your Favorites list, they’ll be listed here and you can select one.

If the provider isn’t on your Favorites list, enter their name or location (state) and click “Search.” 

You can also search for providers in your neighborhood by clicking on the map. An advanced search option that allows you to input zip code, specialty, and other parameters will soon be added.

The search results will appear below the search boxes.

Click on the "Select" button next to a provider’s name to select them. 

You can also add a provider to your Favorites list by clicking on the star next to their name.

Once you’ve selected a provider, you'll be advanced to the next step.

Selecting a Patient

Next, you can select the patient for whom the form will be made out. You can select yourself, a dependent, or “Other.”

If you select yourself or a dependent, the personal details will be automatically filled out and you can proceed to the next step. 

If you select “Other,” you’ll be taken to a page where you can input the patient’s details.

The patient’s first name, last name, and date of birth are required fields.

The patient’s middle name and social security number are optional fields. 

Click “Continue.”

Uploading a Form

In this step, you’ll be asked what type of form you need. Depending on the healthcare provider from whom you’re requesting a form, you may see up to five different types of forms listed. 

If you don’t see the type of form you need listed, select “Other.” This will allow you to upload your own form.

You can drag and drop a file to the appropriate field.

You can also browse for a file and upload it from your computer or drive.

Click “Continue.”

The Patient e-Authorization Form

Here, you can read and sign the patient e-authorization form. 

This is an individual electronic records release authorization form that, when signed, gives the custodian of records—the healthcare provider—and/or ChartRequest permission to disclose or obtain private health information—or PHI. 

You need to sign the patient e-authorization form in order to request form completion. Without a signed patient authorization, the provider and/or ChartRequest is not legally permitted to release or obtain the PHI.

If you want your records release authorization form to specify that only certain PHI is released or that certain PHI will not be released, you can choose to upload your own authorization form. This is helpful if there’s PHI you do not want disclosed. 

Here is an example of a customizable authorization for the release of medical information.

To upload your own authorization form, click on “Browse” and select the appropriate file from your computer or drive.

You can also drag and drop a file from your device onto the upload field.

You can currently only upload PDFs.

Click on “Continue” to upload the file. 

Signing Your Patient e-Authorization Form 

In the “Adopt Your Signature” form that appears next, you’ll be prompted to fill out your full name, initials, and date of birth. These are required fields.

You’ll also be asked whether you’re the patient, the patient’s guardian, or the patient’s power of attorney (PoA). This is a required field.

Your social security number is an optional field.

Fill out the required form fields and click on “Adopt and Sign” to submit the form.

Paying for Your Request Jump 

Next, you can submit your payment for the form completion. 

If you already have a payment method saved to your account, it will appear here and you can select it.

If you want to add a new credit card, click “Add New Card.” Fill out the credit or debit card number, expiration date, and CVC—which is the three- or four-digit code on the back. Click “Save.”

After selecting the payment method you want to use, click “Confirm Payment.” 

Reviewing and Submitting Your Request 

On the next screen, you can review your request. 

If any of the data is incorrect, you can go back and correct it.

When all the data is correct, click “Submit Request.” Your request will be submitted to the provider. Each request has a unique request ID that you can use to search for the request and/or to monitor its status.

When you go to the dashboard or when you click on “Records & Forms” in the sidebar on the left-hand side of the screen, you can see a list of the records and forms requests you’ve submitted.

You’ll receive an email notification when your records are ready to be downloaded.