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- Before fulfilling your medical record request, we’re required to have your “Authorization to Release Healthcare Information” signed by you.
- The medical record information release (HIPAA) form allows a patient to give authorization to a 3rd party and access their health records. The release also allows the added option for healthcare providers to share information. A medical release form can be revoked or reassigned at any time by the patient when a request is received to the clinic from the patient in writing.
- There’s no charge if the Medical Record to be sent Electronically to another medical entity. There will be a postage charge if the Medical Records to be mailed.
- For Medical Record in Paper Format, there’s $25.00 charge for the first 20 pages and $0.50 per page for each additional page plus postage (if to be mailed)
- For Medical Record in Electronic Format, there’s $25.00 charge for the first 500 pages and $50.00 for more than 500 pages
- If an affidavit is requested whether in paper or electronic format, there’s $15.00 charge
- Please allow at least 5 Business Days to process the Medical Records Requests
- Medical Records Requests will be processed by either;
- a patient completing the following Medical Records Request Form
- or a Medical Records Request fax to our fax #855-295-2686
- For questions/concerns about the Medical Records Request, please feel free to send an e-mail to MRs@midcitiespsychiatry.com or call 817-488-8998 ext 2