IRB Patient Data Request Forms

IRB Patient Data Request Forms

• HIM Patient Data Request Form (DOC)
  • 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 to 10 days. Questions? Call 206-884-2625, or e-mail Carol Bettis.
• Research Study Chart Pull Request Form (PDF)
  • 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);
    • A completed Patient List (XLS) that includes at least each participant's name and medical record number; and
    • 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 -mailing all required documents to ChartPullRequestResearch@seattlechildrens.org. You may also send requests in hard copy to HIM Filing at Mail Stop A-4902.
  • The minimum turnaround time for all requests is 7 to 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 206-987-2172, or send e-mail.