Instructions for completing the Authorization for Release of Information:
To request a copy of your medical records, films, cd or x-rays, please click on the appropriate link below for the Authorization for Release of Health Information and deliver in person to the Health Information Management Department.
NOTE: To obtain a copy of your medical records, CD x-ray images or films, a valid authorization MUST contain:
- Patient Information: Provide the patient’s full legal name, date of birth, address and phone number.
- Information Requested: Please be specic regarding what information is to be disclosed and the treatment or time period
- Requester and Recipient Information: For your protection, a photo ID is required to pick-up records.
- Purpose: We are required by regulation to obtain information related to the purpose of the disclosure. Please check the appropriate box in this section.
- Signatures: All appropriate signatures and dates must be provided or request will not be able to be fulfillled. A representative signature (as well as verifying documents as necessary) is required to release records cases where the patient is unable to sign.
Your request may be subject to fees.
AN AUTHORIZATION MUST BE COMPLETED PRIOR TO RELEASE OF INFORMATION, FILMS OR X-RAYS