Medical Records Requests

 

Patients who request a copy of their medical records, and parents or legal guardians who want a copy of their child's medical records, must complete the Authorization for Release of Protected Health Information form.

 

Associates of Internal Medicine accepts the Authorization for Release of Protected Health Information form by fax or other reasonable methods of delivery.

 

The practice charges a reasonable fee for copying a patient's medical record:  $25 for the first twenty pages and $.50 per page for every copy thereafter.  A fee of up to $15 may be charged for executing an affidavit, if requested. 

 

 

Authorization for Release of Protected Health Information
AUTHORIZATION FOR RELEASE OF PHI 1-2015.[...]
Adobe Acrobat document [483.4 KB]

AIMing Higher with Patients

Associates of Internal Medicine

 

817-900-8292 (phone/fax - SAME NUMBER FOR PHONE AND FAX)

 

Or use our contact form.

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