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).

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