[ previous page ]

Requesting medical records

An authorization form is required when you are requesting copies of medical records or asking that we disclose your health information to 3rd parties. If you need your record copies to be sent to another health care provider for treatment purposes, you may either submit this form or merely contact the appropriate facility's medical record department.

Please note that in some cases, a fee will be charged for medical record copies. The facility's medical record department will be happy to provide you information about fees, expected turnaround times and other information related to your request.

We cannot fulfill medical records requests via email or an online form. Please note that if you desire copies from more than one facility, a separate request must be made to each facility as medical records are maintained separately by each site.

Authorization for disclosure of health information instructions

The authorization form is not valid if one or more required elements are left blank. Failure to complete all required elements may result in a delay in processing your request.

Download and print

Section 1.
Fill in your complete name, address, date of birth, daytime phone number and any previous names. The previous names will help us locate older records, if they are being requested.

Section 2.
Fill in the physician, clinic, or hospital that you are giving permission to disclose your information.

Section 3.
Fill in the name of the individual/organization that you want to receive your information. Check SELF if you will be receiving records. If you wish to send a family member or other person to pick up the records, provide that person's name here. Please note that a photo ID will be required in all cases – if you pick up your own records, please be prepared to show your ID. If you name someone else to pick up your records, please make them aware they will need to show their own photo ID.

Section 4.
Enter the date(s) of information you wish to be disclosed. If you are requesting all your records, write in "ALL." If you leave these dates blank, only the past 2 years of information will be disclosed.

Section 5.
Check as many boxes as needed in order to indicate what information should be disclosed. If requesting all records for a certain episode of care, provide a description of the condition or treatment that records should be limited to. If all records are needed, simply write "ALL" on the line provided. If you desire to disclose only limited records, check the "Specific records" box and provide a description of what information should be disclosed. If you need assistance, please ask the Health Information/Medical Record Department for assistance. You may also review your record before completing this form in order to determine what should be disclosed.

Examples of hospital documents include:

  • Discharge Summary
  • Consultation
  • E.R. Report
  • History/Physical
  • Operative Report
  • Pathology Report

Examples of clinic documents include:

  • Physician Visit Notes
  • Occupational Health Exams
  • Medication List
  • Immunization List

Examples of home health documents include:

  • Intake Referral
  • Nurse or Therapy Notes
  • Medication List
  • Discharge Summary

Examples of test results include

  • EKG
  • Lab
  • X-ray/imaging reports

If you do not want mental health records from a certified mental health treatment facility, alcohol/drug abuse records from an AODA treatment facility, or your HIV test results to be disclosed (if these results are part of your records), check the box provided.

Section 6.
Fill in the date you wish this authorization to expire. If you leave this blank, the authorization will automatically expire in one year. You may also list an event.

Section 7.
Check the box or boxes that most closely describes the purpose of the disclosure. If none of the boxes apply, check OTHER and write in the purpose.

Section 8.
This section explains your rights under the law, and includes a notice that the party receiving your records may not be required by law to keep those records confidential. Please note a fee may be charged for record copies.

Section 9.
Sign here if you are the patient. If you are the legal representative of the patient, sign here and also indicate:

  1. Your relationship to the patient, and
  2. Your legal authority to act on the patient's behalf

If you check "parent," and sign this form, you are declaring that you have not been denied physical placement of the minor child by a court of law.

If you are mailing the form in, please direct the correspondence to "Medical Record Dept - Release of Information." If you are calling to ask questions about your request, please ask for the "Medical Record Department - Release of Information."

Find the phone number or address of a facility