Complete this form if you need approval of a new or revised medical record form. Carefully review the following information before submitting:

  • Please submit ONE request for each form (the upload feature only allows a single file). You may upload a draft copy of new/revised forms (preferably as a Word document). For existing or proposed forms, you can scan a pdf or use standard pdf files of edits/revisions.
  • New or revised forms may take 4-6 weeks or longer depending on the complexity of the form or the discovery of clinical issues/findings. The requestor will be notified of the expected delay beyond the normal processing time frame.
  • Each request is submitted to SPH Medical Records Director and SPH Graphics Center. Each will be introduced to the SPH Forms Committee for review and finalizing. Upon Committee approval, forms will be presented to SPH CMO for final approval prior to publishing. 


  • You must use the Edge internet browser to submit this form. Internet Explorer is no longer supported by Microsoft and no longer compatible with our web forms. 
  • If you do not receive a confirmation email after clicking submit, your request did not successfully submit. Please double check to make sure all required fields have been completed and retry submitting.
  • Contact Jenna Cederberg (Ext 2743) with questions.
Please attach the proof of the proposed form.
Please include an attachment explaining the length of the pilot (in weeks).
Please attach a copy of the current form and a proof of the proposed form.
Please attach a copy of the current form and/or a proof of the proposed form.
Example: white copy/Medical records, yellow copy/Patient.
For example, a physician, respiratory therapist, or nurse.
For example, the number of copies.
Please also note the date that these groups reviewed and accepted the contents of the form.
One file only. 2 MB limit. Allowed types: gif, jpg, png, tif, txt, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mp3, zip.