Medical Records Request

Instructions for Requesting Medical Records

PORT Health Services has a process for patients or their personal representative for requesting in writing:

• Copies of their medical record
• That their medical record be sent to another individual or entity

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.

Fees:

• A $6.50 fee if you pick up your records in person in paper form.
• A $6.50 fee plus postage if records are mailed to you.
• A $6.50 fee if you requested an electronic copy.
• If you choose to receive a summary of your protected health information instead of copies of your medical record, you will be responsible for a $11.50 fee plus postage if the summary is mailed to you.

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.

Submission Methods:

• You may submit this form in person to the clinic where you receive services.
• Mail form to:
  • PORT Health Services
    Attn: Medical Record Release Office
    154 Beacon Drive, Suite I
    Winterville, NC 28590
• Fax it to 1-888-856-3428

Fees:

• Reasonable, cost-based charges will apply according to applicable statutes and PORT policies.
• There is no charge for sending your medical records to another healthcare provider.

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.