If you'd like a copy of your medical records to share with a third-party provider or for yourself, please fill out the correct HIPAA Authorization of Confidential Information Form in full and email it to us at email@example.com. Note, the request may take up to thirty (30) days to be processed.
If you are requesting these records be released to yourself, fill out the “Individuals’ Authorization for Release of Confidential Information” form.
If you are requesting these records be released to a third party, fill out the "Third Party Authorization for Release of Confidential Information" form.
We ask that you ensure the following when submitting the form to us to avoid additional delays:
- All writing and responses are clear and legible.
- The information is protected by providing either a "wet" signature or an electronic signature using software that also assigns a digital timestamp (i.e. Docusign).
- If you are unsure of the dates of services you’d like the medical records for, you may write "any and all medical records" in the "Time Period and Restrictions" section located on page 2 of the authorization form.
Requests for Assessments and Paperwork