MEDICAL RECORD REQUEST

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PLEASE PRINT, REVIEW, AND SIGN. SCAN BACK TO OUR PRACTICE EMAIL: info@healthandtherapyforwomen.org

A $20.00 handling charge for processing the request for copies. 

There is then a $0.75 per page for the first through 25th pages

$0.50 per page for 26th through 50th pages

$0.25 per page for all pages in excess of 50

Once full payment is received, we will start processing the record request.

HIPAA allows 30 days for a provider to respond to your request for records. 

Once processing begins, requests can take up to 30 -45 days to be fulfilled. 

We will do our best to get record requests completed in a timely manner.