Medical Records Request

Medical Records Request

Click here to download the Medical Records Request form (authorization to release health information). 

PLEASE NOTE: The release form must be signed.

Patients are able to receive one copy of their medical records free of charge.

Any additional requests are charged as follows:

Base Processing Fee: $23.71 +

• $1.19 per page (pages 1 - 20)
• $0.60 per page (pages 21 - 50)
• $0.23 per page (pages 51+)

Requests will be completed within 30 days of the date they are received. Records can be mailed or picked up in person by the patient.