Medical Records
As of 2/27/24
Request A Release of Patient Medical Records
All requests for medical records must be made using the official release form below. Each office will process the request and the records will be sent within 30 days of receipt of the request. If requesting records from multiple offices, please send a separate request to each office.
For any questions, contact the specific office between 8:00am – 4:30pm Monday through Friday.
Download the official release form below, fill out and return to the address as instructed.
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Instructions (HIPAA Authorization)
- This form requests and authorizes Deborah Specialty Physicians to send your medical records that DSP creates or maintains to the person or entity identified on the form. This form should not be used if you are requesting another health care provider send medical records to Deborah Specialty Physicians.
- NOTE: There may be a fee for the release of the medical records you requested. If a fee applies, you will be informed of the amount before your request is processed. Fees may be based on the number of pages that would be produced for your request as well as the Delivery Options you have chosen.
- IDENTIFYING INFORMATION. Please fill out the patient’s name, address and date of birth.
- RECIPIENT. Please fill out the name, address and phone number of the Recipient. The Recipient the person or entity that is going to receive the medical records. The Recipient of the medical records may be someone other than the patient, such as a caregiver, another health care provider or facility, or an attorney. If the Recipient is the patient, just write “SELF”.
- SERVICE DATE. Please include Service date if you are requesting medical records for another health care provider. The Service date is the date of your appointment with the provider who needs the records.
- DELIVERY OPTIONS. Please check your preferred Delivery Options. Mail, Pick-up, Fax, CD or Encrypted Email. If you want the health information faxed, please include the fax number.
- EMAIL. If you want your medical records to be sent by email, please include the email address. Due to technical restrictions, we may not be able to email all medical records, such as images. Please note that we send emails via encrypted email in order to secure your medical records. If you encounter difficulty receiving the encrypted emails, please contact us to make alternate arrangements. If you request your medical records to be sent via unencrypted email, please note that your medical records are not protected from unauthorized access and you accept any risk that your medical records could be compromised, such as lost in transmission or accessed by the wrong recipient.
- PURPOSE. Please provide the Purpose for the disclosure. If for personal use, write “SELF”. If the medical records are going to another health care provider or facility that treats you, write “treatment, payment and health care operations” purposes.
- DSP LOCATION/PROVIDER NAMES. Please choose the Deborah Specialty Physicians location(s) that you are requesting medical records from, and list any specific physicians from whom you are requesting medical records.
- INFORMATION TO BE RELEASED. Please indicate what information you are requesting. Please include any dates of service/limitations on information you are requesting.
- By completing the “Request for Release of Patient Information” form, you are agreeing that DSP may provide the information requested to the Recipient. This includes any Sensitive Records which could be present in your medical records. For example, an HIV positive test result would be released if you request laboratory results, or medications for depression if you request a list of medications.
- Please sign the form, print your name and include the date. If you are a personal representative with authority to sign on behalf of a patient, please include a description of your authority to sign on behalf of the patient, such as “parent”, “guardian” or “power of attorney”, and a copy of any applicable documentation (guardianship or POA papers).