Medical Records Requests
To inspect or request a copy of your records or your child's records, please print and complete the Release of Information form.
Release of Information
All release of information forms must be complete and accurate.
A valid authorization must include the following:
Name and Date of Birth
A valid phone number where the requestor can be reached
Specific information requested must be initialed
Requested Dates of Treatment must be specific and complete
To whom the information is to be sent - must be complete with name, address, and phone number
Purpose of the authorization
Effective Consent Dates
All statements must be initialed on the release
The individual must print name, provide a signature and date the release
A witness signature must be provided by an individual who has verified the identity of the person requesting information
Individuals 14 and older must complete a release of information for records. Release forms for children under the age of 14 must be completed by a legal guardian
Requests for deceased individuals must include a copy of the death certificate as well as evidence of executorship of the state