Medical Records

Obtaining Copies of Your Medical Records: Release of Information (ROI)

Records can be released to anyone that the patient authorizes (in writing). A valid authorization MUST contain the following information or the request will be returned:

• Patient's full name and date of birth (list any other names the patient may have had
• Hospital Medical Record number (if available)
• Specific information being requested (e.g., type of report/information and dates of service, etc.)
• Purpose for which the information may be disclosed (personal records, continuation of care, etc).
• To whom the information is to be sent (name, address, phone, fax number)
• Specify authorization's expiration date if desired (see Release of Information form below)
• All authorizations are valid for one year unless otherwise requested or revoked by the patient.
• The patient's signature or a patient's legal representative's signature. Authorizations signed by a representative must contain a copy of the guardianship papers or power of attorney
• Date of the signature.