Request Medical Records

Fees:
All records for a requesting physician are free, but must be requested by the physician’s office.

Records requested for personal use are as follows:
Pages 0-10 are free. Any requests over ten pages are $10 + $.50/pg.
To expedite a records request, the cost is an additional $10.

Processing Time:
Requesting Physicians – Immediately
Personal, Lawyer, or Insurance – 10-15 days

How to process a request:
Fax: 801-374-2615
Mail: Central Utah Clinic Medical Records
1055 N. 500 W.
Provo, UT 84604
Phone: 801-429-8062

Forms Required for Release:
All Patients must fill out Forms 1 & 2, the Authorization Release and Agreement to Pay.

Additional Forms:
For the release of a minor’s records - Form 3 (Release for a Minor)
For the release of a deceased person’s records - Form 4 (Release for Deceased Patient)

Release Form Instructions

Release Form 1 - Authorization Release:
This is the standard release form. This is used anytime we release records to another physician, the patient, insurance company, attorney etc…

Release Form 2 - Agreement to Pay:
Explains what we charge for the release of records. It must always be filled out along with form #1, unless records are being sent to another physician. Records must be faxed or mailed to the other physician, not sent with the patient.

Release Form 3 - Release for a Minor:
This form must be completed along with the standard HIPPA for all releases involving the records of a minor.

Release Form 4 - Release for a Deceased Patient
This form must be completed along with the standard HIPPA for all releases involving the records of a deceased patient.

To insure patient confidentiality is protected at all times, “release of information” forms must be signed by patient prior to the release of information to attorneys, another physician, insurance companies or patient.