MEDICAL RECORDS REQUEST
Our office staff will be happy to assist you with requests for your medical records.
We can assist you with the following:
HOW TO REQUEST INFORMATION
To request a medical record, you must complete the “Authorization for Release of Information” form and submit it along with a copy of photo identification, such as a current Driver’s License or State Issued ID. Forms may be completed online, downloaded and emailed/faxed/mailed to us or may be acquired and submitted in person to our Office Manager.
Soul Care, PLLC
Attn: Office Management – Release of Information
5501 Executive Center Drive
Suite 215
Charlotte, NC 28212
email: [email protected]
fax: 888-972-4998
Requests for records will take approximately 10 to 14 days to process.
FEES
There is no charge to send copies of your medical records directly to another health care provider. However, if copies are for a patient’s personal use, photocopy fees will be assessed as follows:
Inclusive of searching, handling, copying, and mailing costs:
We can assist you with the following:
- Access to your medical records
- Obtaining copies of your medical records
HOW TO REQUEST INFORMATION
To request a medical record, you must complete the “Authorization for Release of Information” form and submit it along with a copy of photo identification, such as a current Driver’s License or State Issued ID. Forms may be completed online, downloaded and emailed/faxed/mailed to us or may be acquired and submitted in person to our Office Manager.
Soul Care, PLLC
Attn: Office Management – Release of Information
5501 Executive Center Drive
Suite 215
Charlotte, NC 28212
email: [email protected]
fax: 888-972-4998
Requests for records will take approximately 10 to 14 days to process.
FEES
There is no charge to send copies of your medical records directly to another health care provider. However, if copies are for a patient’s personal use, photocopy fees will be assessed as follows:
Inclusive of searching, handling, copying, and mailing costs:
- $0.75 per page for the first 25 pages
- $0.50 per page for pages 26-100
- $0.25 per page for pages over 100
- Minimum fee of $10.00 permitted
AUTHORIZATION TO RELEASE INFORMATION FORM
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Click the button below to complete an Online Authorization to Release Information
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Download the file below to print, sign and email/fax/mail the Authorization to Release Information. Proof of identification will be required by our office.
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