Download, print and complete the “Patient Authorization for Use and Disclosure of Protected Health Information”. You may also request the form by calling the clinic at which you were/are treated.
Please mail or deliver it to the clinic which you were/are treated.
If you are having records sent to another office please have them send the request so they may specify what records they are wanting.
If you would like to personally pick up your records
Specify on your request that you would like to pick up your records.
Be sure to provide a contact phone number where we can reach you.
If records are needed by a specific date, please specify that on your request.
If you have a personal representative picking up the records please notify the facility and have them bring photo identification when they come.
Is there a charge for the records?
Patients may receive their first copy of records at no charge. If a second request is made for the same records there will be a 0.50 per page charge.
There is never a charge for records requested for continuation of care.
