Obtaining Copies of Your Medical Records

Records can be released to anyone authorized by the patient in writing. A valid authorization MUST contain the following information, or the request will be returned:

• Patient’s full name and date of birth: List any other names the patient may have had.
• Medical Registration Number (MRN): If available.
• Specific information being requested: E.g., type of report/information and dates of service.
• Purpose for which the information may be disclosed.
• Recipient details: To whom the information is to be sent (name and address).
• Authorization’s expiration date: If desired (see ROI form).
• Signature: The patient’s signature or a patient’s legal representative’s signature. Authorizations signed by a representative must include a copy of the guardianship papers or power of attorney.
• Date of the signature.

Need Your Medical Records?

1. Download Request Form

2. Complete Request Form

3. Fax or Email Completed Form