If you move or transfer to a new provider, be sure to request that your new physician be sent a copy of your records. You must be 18 years of age or the parent/legal guardian to request copies of a medical record.

Instructions for Completion

Follow these instructions carefully when completing the authorization form.

  • Type or print neatly.
  • The form must be entirely completed. Failure to do so could result in a delay to process this request to release your medical record information.
  • Patient access fee may apply.

If the individual signing the authorization form is a guardian, executor of the estate, or power of attorney for the patient, that person must submit a copy of the appropriate legal document, which proves authority to act on behalf of the patient. This must accompany the authorization form.

Burgess Health Center: Authorization to Release Medical Information
Burgess Clinics: Authorization for Release Medical Information

Mailing Instructions: The form can not be processed unless it contains the required signatures and date. Mail the completed form and any required legal documents to Burgess Health Center or the Burgess Clinic where your records to be released are located. The address is on the form.

Per HIPAA guidelines, a copy of this form must be retained by the patient. Retain a copy of completed form prior to mailing original to Burgess.