McFarland Clinic

Request Records from McFarland Clinic

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Please complete all required fields so we can process your request in a timely manner.

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Patient Information
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*  A confirmation of your request will be emailed to the address entered here.
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Information to be Released

Limited to 2 years of information unless otherwise specified.

Information to be Released:
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Initial beside any information you do NOT want to be released:


Release Information To
Release To:
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How Would You Like to Receive Your Records?:
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Authorization to Release Protected Health Information

I authorize electronic transmission (fax) of my medical records. Records may be provided in electronic form on a secure disk. Paper records are available upon request.

I understand that if the person(s) and or organizations(s) listed above are not health care providers, health plans or health care clearinghouses, who must follow the federal privacy standard, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards, and my health information may be re-disclosed without obtaining my authorization. This authorization will automatically expire one year from date of signature. I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do, it will not have any effect on the actions they took before they received the revocation. Any refusal to sign this form will not affect my ability to obtain treatment, payment or my eligibility for benefits. I may request to inspect or copy the health information to be used or disclosed. This release is not valid if it does not contain the patient signature.

Legal documentation is required supporting his/her authority to act on a patient’s behalf. Photo identification is requested for all hand carry release of information requests. Facsimile reproductions of the signature are acceptable. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. If additional information is needed please contact McFarland Clinic Release of Information.

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