Health Records

Download, fill-out, and submit the applicable from below.

Please include a copy of your valid identification when submitting email or fax requests.  Be prepared to show your identification upon picking up your medical records.

  1. If you are requesting your own records, or are the legal personal representative ( of the individual and want copies for yourself or to have the records sent to someone, please use this fillable form: Patient Request for Access to Personal Health Information
  2. If you are a third-party (e.g. lawyer, school, insurance company, or employer) please use this fillable form: Authorization to Disclose Protected Health Information
  3. If you are requesting Behavioral Health records, please complete the following release of information (ROI) fillable form: Authorization to Disclose Behavioral Health Protected Information

  1. Download the form.
  2. Open it in Adobe Acrobat Reader, or in a modern browser such as Firefox, Safari, Chrome or Edge.
  3. Type your information into the form.
  4. Then select “Fill & Sign” to use the pen tool for your signature, or initials as requested.

How do I submit my form?

Click to see details




Connect with a Health Records Technician by calling 907.463.6630.