Medical Record Release Request Form

Part A: Patient Information

This section applies to the person whose information or record is being requested.

1) Write the patient’s full name, phone number, email address, and mailing address.

2) Write the patient’s date of birth and last four digits of social security number.

Part B: Person Or Company Who Will Receive Information

Complete this section so we know where to send the information or records.

3) If you are the patient and are requesting the records be sent to you, select “Self”.

4) If the records should be sent to another person or company, write the full name and address of the person or company where we should send the information or records. You must be specific. General terms like “my son” or “my daughter” will not be accepted.

Part C: Information That Can Be Released

This section tells us what information or records you would like us to release.

5) For an abstract or summary of your records, check the first box.

6) For specific records, check the boxes in the second and third columns that apply to you.

7) For all of your medical records, except billing and radiology images, select “Entire Record”. You must specifically select “Billing Records” and “Radiology Images” to receive those records.

8) Check the box where the treatment occurred. If you are unsure, or want records from all treatment locations, check “All Granville Health System Entities”.

9) Write the date range for the requested records. If you want all dates, check “All treatment dates”.

Part D: Purpose Of Request

10) Check the box that provides the reason you want the information or records.

Part E: Format And Delivery Of Information

This section tells us how to send the information or records.

11) If you want an electronic or paper copy of the records, check the box in the first column that applies.

• Encrypted Email- Depending on the size, a PDF copy of the records can be securely emailed to you.
• Thumb Drive/CD- A PDF copy of the records can be put on a thumb drive or CD and mailed to you.
• Fax- We can only fax records to your other health care providers.

12) If you want to authorize Granville Health Systems to discuss the requested information with you or another person/entity verbally, select the “Oral Communications” box in this column.

13) Check the box in the third column to tell us how we should provide the records.

• Electronic- Depending on size, the records can be emailed to you. If you select “email”, the records will be emailed to the email address provided under Part B.
• Mail – If you want the records on a thumb drive, CD, or in paper format, the records can be mailed to you. If you select “mail”, the records will be mailed to the address provided under Part B.
• In Person Pick Up- If you want the records on a thumb drive, CD, or in paper format, the records can be picked up in person at Granville Medical Center- Medical Records Dept. Please specify the name of the person who will be picking up the records.

Part F: Review And Approval

14) Your records may include reference to sensitive types of information. In addition, some records have been marked as sensitive by Granville Health System and will not be released without your approval. If you wish to approve the release of information that has been marked sensitive, check the box(es) that apply to you.

15) If you would like for the Authorization to expire on a specific date or following a specific event, please write the date or event at the bottom of Part F. If no date or event is provided, the Authorization will automatically expire one year from the signature date in Part F.

16) Sign your name, print your name, and put the date on the form. Your name and signature must match the information in Part A. If you are signing the form on behalf of another person, you must complete Part G.

Part G: Representative

If someone other than the patient is signing the Authorization, the person must complete Part G.

17) Print your full name, write your relationship to the patient, and write your phone number.

18) Please check the box to show which legal document you are providing to us that gives you the authority to act on behalf of the patient. You must also provide us with a copy of the legal document showing us that you are authorized to sign the Authorization and include the document when submitting this form.

Mail, E-mail, or Fax a copy of the Authorization to the following address:

Mail: Granville Health System- Medical Records, 1010 College Street, Oxford, NC 27565

Email: roirequests@granvillemedical.com
Fax: 919-690-1814
Call: 919-690-3236

The records will be provided within 30 days of request if the visit was from 2012-present. Other records could possibly require 60 days. The HIM Department is open Mon.- Fri. 8:30 AM – 4:30 PM.

The phone number to call with questions is 919-690-3236 and the fax number is 919-690-1814.