Medical Records Release (Page 2 of 2) in pdf

Medical Records Release Page 2

Tips for Receiving Medical Records Promptly

1. Please fill out the attached form completely, leaving no blanks. Please make sure your complete address is

noted on the request to include the street, city, state, and zip code.

2. Please print clearly!

3. Fax numbers CANNOT be used

4. The “Send Records To:” area must be filled out with a complete mailing address, telephone, and fax numbers.

5. Charges for Records:

a. There will be a charge for records requested by a patient to be mailed directly to the patient

b. There is no charge for the FIRST set of records sent to a physician’s office. After the FIRST request, there will be

a fee for each set of records requested.

c. Requests for/by attorneys, insurance companies, disability claims, and SSI are charged to the requestor.

6. Requests are processed by Healthport. Please allow 30 days for completion of records requests.

7. If the “All” records box is checked, then all records will be sent to the requestor. If the release indicates a

specific time period or specific dates where noted in bold print on the authorization, i.e. OR: Release ONLY the

specific dates of service, then ONLY those records can be sent to the requestor. This is due to HIPAA

rules/regulations. If both the “All” records and specific time period boxes are checked, then only the records

from the specific time period will be forwarded to the requestor.

8. If the requestor requires billing information, the “billing” box must be checked in order for the information to be

released.

Fee Schedule

Please note all charges for copies for Medical Records follow the Current fees allowed by the Ohio Revised code sections 3701.74,

3701.741, and 3701.742, any actual cost of related postage incurred by the health care provider or copy service will also be charged

at actual cost as allowed by law.

Medical Records Release Page 2