We are happy to provide you with a copy of your medical record. To request a copy of your medical record, you, or someone you designate, must complete the Authorization to Release Patient Health Information form. We do not accept requests by phone.
In order to protect your privacy, only the patient, parent/legal guardian or the patient's legal representative can sign the form to disclose medical records. The authorization form must be legible and complete to process your request.
Patients
Click Here to Request Medical Records
You may also follow this link to complete and sign the form electronically in DocuSign:
- Authorization to Release Patient Health Information ‐ https://powerforms.docusign.net/794b4b4f‐8327‐45c6‐8f2c‐46b08aa38c4f?env=na4&acct=afca22f4‐29c3‐47c9‐9f74‐67e7cea8e0f3
- Authorization to Release Patient Health Information – Espanol ‐ https://powerforms.docusign.net/010c8b17‐cbdf‐479f‐8b1c‐43e2d962b90c?env=na4&acct=afca22f4‐29c3‐47c9‐9f74‐67e7cea8e0f3
Fees for Medical Records
Fees for printing copies of medical records are determined by the number of pages:
- $18.53 for the first ten pages
- $0.85 for pages 11‐40
- $0.57 for pages 41+
Copies of records are sent to medical facilities or other physicians at no charge