Medical Record Release Of Information Authorization
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INSTRUCTIONS FOR REQUESTING MEDICAL RECORDS
has retained a professional service to handle the duplication and transfer of
Crozer Keystone Health Network
medical records. The company performing these services is:
Record Reproduction Services (RRS)
600 North Jackson Street
Suite 104
Media, PA 19063
(
Phone:
484)-443-4813 Fax: (610)-471-2275
In order to standardize and expedite all requests for patient information please follow the process below:
1.
Sign, date and completely fill out the Medical Record Release of Information Authorization provided to you. Please include
your phone number and complete address on your request in the event there are any issues regarding the release of your
records.
2.
Submit your signed and COMPLETED Medical Record Release of Information Authorization to the above address, email it
to , or fax it to
(610)-471-2275
3.
There may be a fee for the transfer of your information please use the grid below to determine the correct amount
Transfer to Whom?
Record Type
Charge
Physician
Electronic Only
No Charge
Physician
Paper Chart
$35
Patient
Electronic Only
$20
Patient
Paper Chart
$25
In order for your request to be processed please be sure to fill out all fields on the medical records release form. If RRS cannot determine;
Who you are – Your name DOB and Address
•
The CKHN facility or doctor you are requesting information from – Visit
for a complete list
•
What you need sent – What records, specifically the Dates of Service or body parts examined
•
Where you would like the records sent – Complete address of where you need records delivered too in addition to a Fax
•
number if you would like them faxed
Your signature and when you signed the Medical Record Release of Information Authorization – You must sign and Date
•
the form to be valid
Your records will be released within 48 hours of receipt of the request if you choose only the electronic portion of your chart
You may also pick up copies of your records at the RRS office – Please call to make arrangements.
If you would like we can bill your credit card directly to avoid any bills being sent to you. –Providing a payment upfront may reduce
turnaround times significantly.
If you have any questions on the process or how to complete the form please contact RRS -
Addition resources are available
Record Reproduction Services (RRS)
600 North Jackson Street
Suite 104
Media, PA 19063
(
Phone:
484)468-1299 Fax: (610)-471-2275
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