Demographic Information. Please enter the following: name, address, phone, date of birth, last four digits of your Social Security Number.

Section 1 asks, "What part of the medical record do I need?" The complete medical record contains every entry in our electronic system and may be considerably more information than you need. If you want more specific and/or limited information, choose the appropriate items under [OR the records marked below:], i.e. History & Physical, Operative Report, Discharge Summary, etc.

Section 2 does not need to be completed unless you are asking for records that are outlined in this Section. If you are asking for these records, then choose the appropriate item and include your signature where indicated. If you are not requesting records outlined in this Section, you do not need to complete this area of the form.

Section 3 asks, "How would you like your request to be handled?" Please be advised that in order to process your request, a valid Photo ID with a signature, must be included with your authorization form.

Section 4 asks, "How long is this authorization is valid?" If you do not list a specific date in the space provided, the authorization will be valid for a period of 90 days from the date of your signature. This Section requires that you provide your initials in the space provided.

Section 5 outlines your Individual Rights as they pertain to this authorization form.

Signature / Date / Time: In order to process your request, this section must be completed.

Cost For Processing: A fee of $0.25 per page will be assessed for paper copies. If you would like your information placed on a CD, a $5.00 fee applies. If you have questions related to the cost of obtaining your records, please contact the facility directly. (See below)

Submit the completed authorization form in person, by fax, or by mail to the appropriate Medical Records Department where you received your care and treatment.

Complete the second page of the document, titled PATIENT OPT-OUT REQUEST FORM.

Include up-to-date contact details.

Sign and date the document. In order to process your request, the entire document must be completed, including the signature.

Submit the completed authorization form in person or mail to the appropriate Medical Records Department where you received your care and treatment. You can also mail the completed form to: