IRB Patient Data Request Forms

As of March 1, 2016, all new applications, modifications, renewals, reportable new information and other work must be submitted to the HSPP via Click IRB. Visit the Click IRB Resources page for additional information.

• 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. Note: HIPAA information is now included as part of the consent form in Click.
  • You may submit your request after it has been completed and signed by scanning and then emailing all required documents to [email protected]. 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.