Request Medical Records
Fees for records requested for physicians:
All records for a requesting physician are free, but must be requested by the physician’s office.
Fees for records requested for personal use:
$0.50 per page for the first 40 pages
$0.30 per page over 40 pages
Fees for records requested for Attorney's, Insurance, etc:
$20 basic fee
$0.50 per page for the first 40 pages
$0.30 per page over 40 pages
Fees for Radiology Images:
$20 per disc
Processing Time:
Requesting Physicians – Immediately
Personal, Lawyer, Insurance, etc. – 10 to 15 days
How to process a request:
Fax: 801-374-2615
Mail: Central Utah Clinic Release of Information
1055 N. 500 W.
Provo, UT 84604
Phone: 801-429-8062
After records are copied you will be invoiced by:
HealthPort
120 Bluegrass Valley Parkway
Alpharetta, GA 30005
To pay online, please visit: www.HealthPortPay.com. They accept Visa, MasterCard, American Express, and Discover. Telephone payments can be made at 1-800-464-0035.
Should you have any questions regarding your request please contact:
HealthPort
1-800-367-1500
www.healthport.com
Release of Information FAQ's:
- Questions about requesting records
- How do I fill out the authorization form?
- Example of a valid completed authorization
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 - Affidavit for Deceased Patients
This form must be completed for all releases involving the records of a deceased patient. The request must also include a death certificate and authorization signed by individual authorized in the affidavit.
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.
