HIM maintains the legal medical record for all Orlando Health patients. Requirements/Tips. Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870; Medical Examination Report (MER) Form, MCSA-5875; Medical Examiner's Certificate (MEC), Form MCSA-5876; 391.41 CMV Driver Medication Form, MCSA-5895 (optional) Medical Exemptions Diabetes Package. Encinitas, CA 92023-5498. com or by fax to 1−630−873−8797. PO Box 235498. Fax. recordsrequest@scrippshealth.org. 760-633-7747. Medical Records & Release Forms. Medical Examinations. Request that your medical records be released to someone else. Most practices or facilities will ask you to fill out a form to request your medical records. Authorizations must be signed by the patient or the patient’s legal representative. The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file.This document allows a patient to list the names of family members, friends, clergy, health care providers, or other third (3rd) parties to whom they wish to have made their medical information available. Electronic medical record; Laboratory test results; Radiology and diagnostic testing results; If the information required is not found in the FollowMyHealth patient portal or an official copy is needed, please follow the instructions below and complete the Northwell Health Authorization form to help us process your request. Appropriate address and fax numbers, along with a contact number for more information, are listed further below on the page. Emails requesting medical records must include a completed Authorization for Disclosure of Health Information form (see above). Release of Information Center. Submit your completed paper authorization form to Record Connect by emailing a copy to dupage. status@ recordconnectinc. Our Release of Information Department is responsible for providing patients, along with third party requestors, copies of medical records and imaging. This often involves a fee. A specific medical release form for the ear specialist would limit the type of information shared for that receiver. You can: Review the information in your medical records. By Paper Form. To receive a copy of your medical record, print out and complete our authorization form below and mail or fax it to the hospital or facility where you received service. This request form can usually be collected at the office or delivered by fax, postal service, or email. Be absolutely clear who should receive the information by creating fields for business name, name of the healthcare provider, address, email, phone number, place of business, and other identifying information. Please note, a written request needs to be provided prior to processing. To request a copy of your medical record, you may stop by the Medical Records office at Ingalls, Monday - Friday, 8:30 a.m. to 5:00 p.m. to fill out a request or complete the Ingalls Authorization for Release of Information and mail it to:. Requests for continuing medical care: Complete and submit the Authorization for Release of Information form, or complete the request form from the physician or other health care provider's office. Request a copy of your medical records. Dartmouth-Hitchcock keeps a private, secure medical record about your health. Email. Medical records at UChicago Medicine Ingalls Memorial are kept for ten years. Medical emergencies will be faxed upon confirmation of patient's presence at … UChicago Medicine Ingalls Memorial If the office doesn't have a form, you can write a letter to make your request. If you prefer to complete a paper authorization form, please download and print the Authorization for Release of Health Information Form.