Release of Medical Records

This form should be utilized to request copies of your information or to direct copies of your report to be sent to a third party.

• Patient Request for Health Information
• Patient Request for Health Information - Marshallese
• Patient Request for Health Information - Spanish
• Patient Request for Health Information - Vietnamese

Utilize the Authorization for Release of Health Information form to authorize a third party to obtain copies of your health information.

• Authorization for Release of Health Information Form
• Authorization for Release of Health Information Form - Marshallese
• Authorization for Release of Health Information Form - Spanish
• Authorization for Release of Health Information Form - Vietnamese

Identification is required to obtain health information.  Personal representatives should provide documentation to prove legal representation.

Acceptable IDs include:

• Driver’s License
• Employment ID
• State Issued ID
• Current School ID
• Military ID
• VA ID
• Valid, Current Passport

Legal Documentation includes:

• Power of Attorney for healthcare
• Legal Guardianship papers
• Order of legal representation

Request Medical Records by Mail

Request Medical Records Via Fax

405-552-8704 (patient and care providers)

405-552-8701 (all other requestors)

Request Medical Records Via Email

[email protected]

Medical record copy fees my be applied as below pursuant to federal regulation 45 CFR 164.524 (c)(4).

• Patient or patient representative requests:
  • Electronic Delivery: Flat rate fee of $6.50 if records are in electronic format and delivered on electronic media. In addition, $0.12 per page if any of the records are maintained on paper.
  • Paper Delivery: $0.12 per page plus labor cost, shipping supplies, actual postage, and sales tax.
• 3rd party requests (i.e. attorneys or insurance companies):
  • $10.00 flat fee plus $0.30 per page for paper or electronic delivery. Total charges are capped at $200 if the entire request can be reproduced from an electronic health record in the specified format requested and delivered electronically.

X-rays, photographs, images, or pathology slides are a flat rate of $5.00 each.

Request for Amendment of PHI

• Request for Amendment of PHI
• Request for Amendment of PHI - Marshallese
• Request for Amendment of PHI - Spanish
• Request for Amendment of PHI - Vietnamese

Request for Release Restriction

• Request for Release Restriction
• Request for Release Restriction - Marshallese
• Request for Release Restriction - Spanish
• Request for Release Restriction - Vietnamese

Request for Accounting of Disclosure

• Patient Request for Accounting of Disclosure
• Patient Request for Accounting of Disclosure - Marshallese
• Patient Request for Accounting of Disclosure - Spanish
• Patient Request for Accounting of Disclosure - Vietnamese

Portal Proxy Request for Minor Child

• Portal Proxy Request for Minor Child
• Portal Proxy Request for Minor Child - Spanish
• Portal Proxy Request for Minor Child - Vietnamese

Portal Proxy Request for Adult

• Portal Proxy Request for Adult
• Portal Proxy Request for Adult - Spanish
• Portal Proxy Request for Adult - Vietnamese

Request to Revoke Proxy Access

• Request to Revoke Proxy Access
• Request to Revoke Proxy Access - Spanish

Opt-Out of INTEGRIS Health Information Exchange

• Opt-Out of INTEGRIS Health Information Exchange
• Opt-Out of INTEGRIS Health Information Exchange - Spanish
• Opt-Out of INTEGRIS Health Information Exchange Revocation Form
• Opt-Out of INTEGRIS Health Information Exchange Revocation Form - Spanish

Reproductive Health Records Disclosure Attestation

• Attestation for a Requested Use Related to Reproductive Health Care