Medical Records Release Form

Please correct the errors described below.

Fees for Copies of Health Information

In order to better serve you, our facility contracts with HealthPort to process your request for copies of medical records.

There will be a minimum fee of $10 charged for reproduction of records unless you are referred by our facility to another provider.

Effective January 1, 2008, fees per page will be the following:

$.75 per page for 1-25 pages

$.50 per page for 26-100 pages

$.25 per page for 100+pages

Plus actual postage

All invoices will be billed by HealthPort. Upon receipt of your invoice, simply include the bottom portion of your invoice along with your check for the balance due. Your invoice will include a phone number if you choose to pay by credit card or you may go to to pay your invoice. If you have any further questions, feel free to contact HealthPort customer services at 1-800-367-1500.


Specifically, I would like to:

I would like the following records:

Sender’s Information:

Recipient’s Information:

I understand that I may be charged a fee for the preparation of a summary or explanation of my child’s protected health information. I also may be charged a fee for reproduction costs to obtain a copy of my child’s protected health information or to obtain a copy of the summary or explanation. If I ask to have the information mailed to me, I understand that I may be charged a fee for mailing costs. If I ask for an electronic copy of my child’s protected health information, I understand that I may be charged a fee for the media (CD, flash drive) on which my copy is stored and provided to me and for the labor costs associated with making the copy.

responsible if the information e-mailed is intercepted by an unauthorized third party.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.