IRB Patient Data Request Forms

HIM Patient Data Request Form (DOC 70KB)

Use this form to generate a patient data request related to Research, QI, or Administrative Planning. You must complete this form and send it to the HIM Patient Data Department, mail stop A-4902.

If this is a research request, the IRB number must be supplied before the request can be fulfilled. The minimum time allocation for any request is 7-10 days. Questions? Call (206) 884-2625, or e-mail Carol Bettis.

Research Study Chart Pull Request Form (PDF 95KB)

Use this form when requesting paper medical records from HIM Filing for an approved research study. HIM Filing does not accept research requests through INVISION.

This form must be filled out completely by the requestor, and it needs to be signed by an investigator approved by the IRB. The request must include:

  • A completed Research Study Chart Pull Request Form (PDF 95KB);
  • A completed Patient List (XLS 22KB) that includes at least each participant’s name and medical record number;
  • A copy of each participant’s HIPAA Authorization form if HIPAA authorization is required.

You may submit your request after it has been completed and signed by scanning and then emailing all required documents to ChartPullRequestResearch@seattlechildrens.org. You may also send requests in hard copy to HIM Filing at Mail Stop A4902.

The minimum turnaround time for all requests is 7 - 10 days. The maximum number of medical records to be requested at any one time cannot exceed 30. HIM Filing will notify you when the records are ready or if there is a problem in filling your request.

Questions? Call 206-987-4469 or 987-2172 or send email.