Requesting Medical Records and Radiology CD's 

Records Needed for Continued Care: 

Upon request, we will send pertinent records to your physician for continued care at no charge. Pertinent records include: 

• All dictated doctors reports including, but not limited to, the following: Discharge summary, Emergency room dictated reports, History and Physical, Consultations, Operative Reports, Cardiodiagnostic Reports, Cardiac Ultrasound, Stress Tests, TEE Reports, EEG Reports, Sleep Lab, Pulmonary Function reports.
• Pathology Reports/Cytology Reports 
• Implant Summary Sheets 
• Labs 
• Radiology Reports 
• EKG 

All Other Request for Medical Records: 

• A copy fee will be charged for copies if the number of pages exceeds 20 pages. 
• Any records request over 20 pages will be put on CD ONLY, cost is $20.00 per CD. 
• If the records requested are in off-site storage, records can be put on CD, however it will be charged at a higher rate. 

Completing the Medical Records Release Form: 

To avoid delay in processing your records request, the Medical Records Release Form must be filled out completely. The following sections of the form are routinely not completed correctly. Please read the following 3 bullet points for guidance in completing the form: 

• Section 1 identifies the patient: Please include date(s) of service needed. 
• Section 1.A indicates who the records will be disclosed to: Please check whether records are to be mailed or picked up. Records can be faxed to a medical facility ONLY. 
• In section 2 is a description of records to be released: Please be specific when indicating what information is needed. 
• Please sign and date under Signature of Patient when patient is requesting records. 
• If records are being requested by someone other than the patient, please provide proper documentation proving the right to patient’s medical records such as a Health Care/Medical Power of Attorney, a death certificate, guardianship, etc. The person listed in these documents must sign and date under Signature of Representative 

Radiology CDs

If Radiology images are needed, please specify, otherwise only dictated reports will be provided. The fee for radiology CD’s is as follows: 

• CD’s are free if taking to another Physician. 
• For personal use: 
  • CDs 1-5 are $20.00 
  • CDs 6-10 are $5.00 each 
  • CDs 11-up are $1.00 each 

Please feel free to contact the Medical Records Department if you have any questions. The address, phone and fax number for each campus is located at the top of the Medical Records Release Form.