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Patient Release of Information Form

Medical Records Request Form


Release of Information

Release of information means a document that allows a program to release client information to designated person(s) with the client’s written consent, in compliance with the Federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule at 45 CFR Parts 160 and 164, Subparts A and E; and the Federal Confidentiality of Alcohol and Drug Abuse Patient Records regulation at 42 CFR Part 2.

Medical Records Request

Patients requesting a copy of their own medical records, legal guardians, or patient representatives with a power of attorney please download the forms below. You can email, fax, or bring forms in person. Please allow up to 5 business days to receive your records.

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