PORT Health Services has a process for patients or their personal representative for requesting in writing:
For requesting a copy of your Medical Record:
Read carefully the form “Medical Records Request”. Complete the top section ONLY. It is essential that you list your current and accurate contact information and check all applicable boxes.
Submission Methods: You may submit this form in person or mail it to the clinic where you receive services.
For requesting a copy of your Medical Record to be sent to another individual, entity, or other healthcare provider:
Complete the form “Authorization for Use and Disclosure of Protected Information”. Please ensure that all necessary information is provided along with signature(s) and date(s) for PORT to process your request.
Please note: Only complete forms with valid consents will be processed in accordance with applicable laws and PORT’s policies.
For questions regarding record releases, you may call 252-353-1114 and ask to speak to a Record Releases Associate.