PURPOSE: Complete this form to initiate a request for, and/or to send confidential documents. See instructions below on how to use this form.
Please correct the errors described below.
NOTE: THIS IS NOT AN AUTHORIZATION FOR RELEASE OF INFORMATION FORM!!!
1. If you do NOT have a completed ROI form, please complete and submit the Secure File Transfer form. Medical Records staff will contact you with instructions on how to obtain records, including a link to complete an online ROI form.
2. If you DO have a completed ROI form, complete the Secure File Transfer form and attach the ROI to submit along with this form.
3. Patients/Clients requesting records must attach a copy of their current photo ID for identity verification purposes.