Medical Records Release of Information Form

Click to download the Release of Information Form.

Fee Schedule for electronic request of personal health information:



• Labor Charge Small (0-100 pages)


• Labor Charge Large (100+ pages)


• Encrypted USB Drive


• Expedition Charge 


• Certification Charge 


• Postage Due (current rate) 


• Fed Ex Overnight Express 

                 Rate Varies Upon destination 

** Please note this fee schedule is cost based, including the average labor costs to complete production of the ePHI as requested.  The fee does not include labor for reviewing the access request, searching, retrieving, segregating or any other preparation done prior to copying the ePHI.

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