Medical Records Release Form

When requesting copies of your medical records, we ask that you please allow a minimum of two business days to prepare your request for pick-up. For your convenience, you may print the Authorization for Release of Medical Information Form and present it to your provider's office.

A patient may request records for:

  • Your own personal use (*charges will apply);
  • To leave your current provider and have your medical care transferred to a new practitioner in another clinic (*charges will apply); or
  • When your provider has referred you to the care of another provider or specialist (no charge).


*Charges
There is no charge for medical records if copies are sent to health care providers / facilities for ongoing care of follow-up treatment. There is an administrative fee for copies made for personal use or when transferring all care to another provider. These fees are:

Pages 1-25=$.92 per page                  Pages 26-50=$.61 per page                    Pages > 51=$.31 per page