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Forms and Policies

IRB Patient Data Request Forms

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  • 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 Epic.
    • 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
      • 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 MS OC.6.820.
    • The minimum turnaround time for all requests is seven to 10 days. HIM Filing will notify you when the records are ready or if there is a problem in filling your request.
    • Questions? Call 206-987-2172 or email.
     

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