To
request medical records, please complete the
Authorization for
Release of Patient Information.
Download form using this link
Release of Patient Information.
When completing/returning the authorization,
please be advised of the
instructions/updates below:
-
All sections of the authorization form
must be completed.
-
A complete mailing address to where you
want the records mailed is necessary to
process your request.
-
We do not fax records to any location
other than to a physician's office or a
hospital for continued patient care.
-
If you choose the option to pick up your
records, the person picking up the
records must be either the patient or
the designated person that is documented
on the authorization. We will call you
when records are ready for pick up.
-
Please include your telephone number so
that we can contact you if any questions
arise.
-
If you have a medical care appointment
scheduled, please put the date & time of
your appointment at the top of your
request. We will ensure that the
records are delivered prior to the
appointment.
-
To request medical records for someone
other than yourself, the patient must
sign the authorization or you must
present a Power of Attorney. If the
patient is deceased you must present an
official copy of a Certificate of Death.
-
Please include a copy of the patient's
photo I.D.
Adobe PDF documents that can be opened
and printed using
Adobe Acrobat Reader. To download the
free Adobe Acrobat Reader from Adobe's Web
Site click on the Get Acrobat Reader button.
When the "File Download" window appears you
will need to install the free
Acrobat Reader from Adobe. Choose "Run
this program from its current location" and
click "OK" follow the download and
installation instructions then, return to
this page view and print the scheduling
forms.
To print use the Print icon ( ) in
the Acrobat Reader tool bar.
To save
these documents to your computer right click
on the document
title and click on Save
Target As... from the pop up menu.
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