Patient Request For Medical Records

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Patient Request for Medical Records
Please complete all required sections marked with an asterisk*
*1-Patient’s Last Name
*2-Patient’s First Name
3-Patient’s Middle Name
*4-Patient’s Date of Birth
5-Other Names Patient is Known By (if applicable)
*6-Address of Person Signing Form
*7-Phone number of Person
Signing Form
Okay to leave a detailed message?
Records are to be sent to this address
Yes No
Yes No
(if no, complete Box 12 &13)
*8-Description of Records Being Requested 
For Time period From ____________________ to _______________________
Hospital *From (Name of Legacy Hospital (s)): ________________________
 May include: Patient Demographics, Discharge summary, History & Physical, Consultation, Operative /
Procedure notes, Emergency Dept notes, Lab results and Imaging/ Diagnostic results.
Clinic *From (Name of Legacy Clinic(s)): _____________________________
May include: Patient Demographics, Ophthalmology Reports, Medication Information, History &
Physical, Procedure notes, Consultation, Lab results and Imaging/ Diagnostic results.
Billing Records From (Name of Legacy Facility): _______________________________________
Other (List Legacy Location and Type of Records): _____________________________________
 Legacy Health will charge and collect fees from the person signing this form.
 Medical records will be mailed to the address listed in Box 6 of this form, unless otherwise indicated by filling in
Box
12.
Records are only sent to one address per request form. We do not fax records.
 Legacy Health may deny this request under limited circumstances as provided in federal regulations governing
the use and disclosure of protected health information. I understand that, except as otherwise permitted under
applicable law, I have the right to have a denial of my request reviewed by a licensed independent practitioner
selected by Legacy Health who did not participate in the decision to deny my request.
To request an electronic copy of medical information contact Legacy Health Release of Information
Office at: (503) 413-2762
*9-Today’s Date
*10-Patient or Authorized Person’s Signature
*11-Name of Person Signing Form & Relationship to Patient (Documentation of authority to sign is
required if signed by anyone other than the patient or the parent of a child under 18 years old.)
Parent or Other (Print Name): ___________________________________________
Patient
If you are requesting records be sent to another party please fill out the information below
12 –Name and Address of receiving party
13- Phone number of receiving party
(9/13)
306833

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