Once received, records releases need to be signed off by the ordering physician. Please allow adequate response time.
Please provide phone number, and either the address or fax number for where you want records sent if they are not being sent electronically.
Please be aware that records requested in paper format may be subject to a .75 cent per page processing and copying fee.
PLEASE WRITE FULL BELOW TO SERVE AS AN ELECTRONIC SIGNATURE ACKNOWLEDGING THE FOLLOWING: I understand that I may refuse to sign this authorization. Treatment, payment, enrollment in a health plan or eligibility for benefits will not be conditioned on signing an authorization if to do so would be prohibited by federal or state law. I understand an authorization may be require to participate in research or where health care services are provided solely for the purpose of creating health information for a third party, and that if I refuse to sign an authorization those services may be denied. I may revoke this authorization in writing. If I do, it will not affect any previous actions already taken in reliance upon my authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. I may revoke this authorization by writing a letter and mailing it by certified mail, return receipt requested, to the Privacy Officer at the health care provider listed above. Once health information is disclosed pursuant to this authorization, it may be re-disclosed and may no longer be protected by privacy laws.