Patient Release of Medical Records – Self/Other
Important Note
In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), individuals are entitled to access, inspect, and/or obtain a copy of their protected health information (PHI).
Please anticipate a processing time of up to 30 days. Should you require any assistance, kindly contact Customer Service at: 877.485.5336.
All requests for the disclosure of protected health information are administered by the Medical Record Department. Your medical record is maintained in the utmost confidentiality at all times.
Please complete each section of the request form carefully. Only fully completed forms bearing your physical signature and returned with a copy of your state-issued identification will be processed.
Medical Records Release Instructions
- Complete the provided request form and return it along with a photocopy of your state-issued photo identification document.
- Ensure that all pertinent information is carefully filled out and the appropriate checkboxes are checked. Your completed form will be reviewed, and we will promptly contact you via email or phone if any clarification or additional information is required.
- Upon the successful completion of your test, the results will be disseminated to a secure portal that your ordering provider has established with us.
- The Medical Records Department has a 30-day window to provide you with a copy of your test results. If you need a copy prior to the stipulated timeframe, kindly reach out to your ordering provider.
- To mitigate potential delays in the processing of your request, please verify that your form is fully completed, including the inclusion of your physical signature. Additionally, ensure that you include a copy of your photo identification document.
Click the form image located on this page to initiate the form submission process. This will redirect you to a new window where you can conveniently complete the form, print it, sign it, and send it to us with an appropriate copy of your photo ID.