Medical Records Request Forms

Use the following forms to request medical records for yourself or someone who has given you written permission.

• Authorization to Disclose Protected Health or Billing Information (For Third Party Access to PHI)
• Autorización para divulgar información médica protegida o de facturación (Spanish - For Third Party Access to PHI)
• Instructions for Completing the Authorization to Disclose Health or Billing Information Form
• Patient Request for Access to Protected Health Information (For Patient Access to PHI)
• Solicitud de acceso del paciente a informacin médica protegida (Spanish - For Patient Access to PHI)
• Request to Exercise Privacy Rights Amendment of Medical Record
• Request to Exercise Privacy Rights Restrict the Use or Disclosure of PHI