Medical records request form pdf

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Medical records request form pdf, answers, and forms you will need to obtain your medical records from the University of Chicago Medicine. 2017 The University of Chicago Medical Center, All Rights Reserved. Who is authorized to sign for release of my health information?

How much does it cost to obtain a copy of my health information? When will I receive a copy of the medical record? Who do I contact if I have questions? UC organization that maintains your health information. You can submit this form to the appropriate UC organization by mail or in person.

If you are submitting your request in person on the University of Chicago Medicine campus, you may do so from 8:30 a. If you are hospitalized, you may submit this form at the Admitting Office near the Mitchell Hospital lobby, when you are discharged from the hospital. If you are unable to locate the activation code or need assistance, please contact UCM Connect at 1-888-824-0200. Legal document must be provided. Proof of guardianship document must be provided. Copy of the death certificate and a copy of the representative of estate documents must be provided. There is no charge for processing copies of health information directly to other healthcare providers.

Patients will be charged a fee for copies of their health information. To reduce the cost, patients should consider requesting specific information rather than a complete record. Records will not be released until payment is received. 66 per page regardless of the number of pages requested. Copies are processed within 15 to 30 days from the date the request is received by a UC organization. Recipients will be notified if the request cannot be processed within that time frame.

If you have any questions, please contact the UC organization responsible for maintaining your records. A complete list of organization addresses and phone numbers is included in the instructions for completing the request and authorization form. 2017 The University of Chicago Medical Center. Please forward this error screen to sharedip-23229239193. Learn how to request a copy of your medical records at Massachusetts General Hospital. If you have an urgent need of copies of your medical record or have questions regarding your request, please contact 617-726-2361 and visit the medical records copy office at Mass General, located on the eighth floor of the Founder’s Building. Medical records include a patient’s medical history, pathology, radiology, lab reports and operative reports of treatments and medical services.