Request medical records

• If the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
• Multiple requests are authorized if the purpose of the request remains the same.
• I have a right to revoke this authorization at any time and if I revoke this authorization, I must do so in writing and present the written revocation to the department that I have authorized to release the information.
• Any revocation will not apply to information that has already been released in response to this authorization.
• I need not sign this form to ensure health care treatment.

• No charge for pages 1-10
• .50 cents for each page from 11-40
• .33 cents for each additional page

Additionally, an initial set of radiological films/CD-ROM can be provided at no cost to a patient for physician or facility referral. (A signed authorization is required for HIPAA compliancy).

However, a fee of $6.50 per sheet of film and $6.50 per CD-ROM will be charged for additional copies.