This page is designed exclusively for healthcare providers and HIPAA-covered entities who need access to patient records for treatment and continuity of care purposes. Important: This request process is not intended for patients, families, or personal representatives.
Patients seeking access to their own medical records should click here.
Please complete the form below to request copies of medical records. All fields marked with an asterisk (*) are required. Requests submitted through this portal must come from licensed healthcare providers, hospitals, clinics, or other entities directly involved in the patient's care. Requests are processed on a first-in, first-out basis and fulfilled as quickly as posssible to support patient care.
Disclaimer: This portal is intended solely for continuity of care requests submitted by covered entities. Requests submitted by patients, family members, or personal representatives will not be processed through this system.
Federal and state laws protect the information disclosed pursuant to this Authorization. I understand that if the authorized recipient of the information is not a healthcare provider or health plan covered by federal privacy regulations, the information may be re-disclosed and no longer protected. However, the recipient may be prohibited from disclosing substance use disorder information under the federal confidentiality requirements for substance abuse patient records as Federal Law 42 CFR Part 2 prohibits unauthorized disclosure of these records. Such information may not be used to criminally investigate or prosecute a substance abuse patient. Further, state law prohibits a recipient from making any further disclosure of test results relating to HIV or AIDS without the specific written consent of the person to whom such information pertains. A general authorization for the release of medical or other information is NOT sufficient for such purpose.
Please complete verification below:
