Medical Records Request

REQUIRED DOCUMENTATION FOR MEDICAL RECORDS

A Medical Records Request Form is required when you are requesting copies of medical records or asking that we disclose your health information to any third-parties.

The Medical Records Request Form is not valid if one or more required elements are left blank. Failure to complete all required elements may result in a delay in processing your request. All request, whether delivered in person, by mail, or via fax, require 7-10 business days to process.

No same day requests will be accepted.

Download Form, Print & Fax Option

Digital Form Option

Name*
First Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
I hereby request that Falck Southeast II, Corp. (“Falck”) provide me with a copy of the following:
Requested Records*
Please check all boxes that apply
- My medical records
- Any other personally identifiable information used by Falck to make medical and billing decisions about me
Range of Request*
Check only one box
- I am interested in accessing or obtaining a copy of ALL Requested Information maintained by Falck.
- I am ONLY interested in accessing or obtaining a copy of Requested Information relating to the following date(s) of service:
From...
To...
I understand that any information provided to me pursuant to this request will not include (i) information compiled in reasonable anticipation of (or for use in) a civil, criminal, or administrative proceeding or as may otherwise be required by applicable law, or (ii) if I am a parent or legal guardian requesting access to a minor’s information, records related to certain categories of treatment as required by law.

I understand that Falck may deny this request under limited circumstances permitted by federal regulations governing the protection of personally identifiable health information.

I understand that Falck will notify me of its decision to approve or deny my request to access or obtain a copy of the Requested Information within thirty (30) days of receiving this request if the information is maintained or accessible on-site at Falck, or within sixty (60) days if the Requested Information is not maintained or accessible on-site at Falck. If Falck is unable to comply with my approved request within the applicable time limit, it may extend the applicable deadline for up to thirty (30) days by notifying me in writing.

I understand that Falck will charge me $0.50 per page for copying fees and that there may be an additional fee for clerical work necessary to complete my request, as well as any applicable mailing fees.
Pick Up or Delivery Preference*
Check only one box
- I would prefer to pick-up or view the Requested Information at the appropriate Falck location
- I would prefer to have a copy of the Requested Information mailed to me at the following address:
Address
Street Address Address Line 2 City State ZIP Code
Signature of Patient (or Personal Representative)*
Printed Name*
Today's Date*
Relationship to Patient
If applicable

MEDICAL RECORDS REQUEST

REQUIRED DOCUMENTATION FOR MEDICAL RECORDS

Download Form, Print & Fax Option

Digital Form Option

I hereby request that Falck Southeast II, Corp. (“Falck”) provide me with a copy of the following: