Authorization to Release Health Information

Orchard Medical Center, S.C.

Please correct the errors described below.

I request and authorize Orchard Medical Center, S.C. to

healthcare information on the patient names above to:

in Medical Records Dept.

This request and authorization applies to:

ALL Healthcare Information

(The above named person is required to present a picture ID (state ID or valid Driver’s License) to our staff before forms are to be released)

Please allow up to 14 business days to process your request

I understand by signing below I have the right to inspect or copy the records that are being released. I agree to sign this authorization and understand I will be given a copy once I have signed. I also understand I will need to submit a written letter of cancellation to the Medical Records Department if I choose to cancel this authorization.

2018 Copying Fees – (www.ioc.state.il.us) FOR IN OFFICE USE ONLY

  • Handling Charge ($27.91)
  • Copy pages 1 – 25 ($1.05)
  • Copy pages 26-50 ($0.70)
  • Copy pages in excess of 50 ($0.35)
  • Copies made from microfiche or microfilm ($1.74)

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