Request Records

Your Options

If you would like to request a copy of your medical records and/or X-rays, we offer you several options:

Call our office at 239.596.0100, ask for the Office Manager to assist you

Print out copy of our release form to fax to our office at 239.596.6737. Click this link for Release Form. (61.2 KB .pdf)

Complete our on-line request form (below)

Please note: Your insurance company or attorney must request medical records in writing with your signed authorization form.

On-Line Request for Medical Records or X-rays

Please review the following.

I understand that the information in my health records may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol or drug abuse.
I understand that this authorization shall expire one year from its effective date, unless it is revoked prior to the expiration date.
I understand that I have the right to revoke this Authorization by providing written notice to the attention of the HIPAA Privacy Officer at Zehr Center for Orthopaedics. The revocation will be effective upon receipt except with respect to uses or disclosures made prior to receipt and in reliance upon this Authorization.
I understand that once the requested information is disclosed pursuant to this Authorization, Zehr Center for Orthopaedics will no longer have control over the information and there is a potential that it may be re-disclosed by the recipient and may not be protected by the Privacy Rules under the Health Insurance Portability and Accountability Act.
I understand that Zehr Center for Orthopaedics cannot require that I sign this Authorization as a condition to the providing of services.
I am entitled to a copy of this signed Authorization Form upon request.

If you are in agreement with the above, fill out the form below.

Use this form to request a copy of your medical records or X-rays to be sent to you or another health care provider. Please do not use this form to request records to be sent to an insurance company or attorney.

Request Records

"*" indicates required fields

Patient Information

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Email*

Patient Account Number*

Contact Person*

Patient/Contact Phone*

Best time to reach you*

Information Requested

I authorize Zehr Center for Othopaedics to DISCLOSE (RELEASE) the following Protected Health Information, by any acceptable means, including fax:

Please check one or more of the following and provide detailed information about what you would like released, including the treating physician, dates of service, and/or relating to what condition.

Office Notes*

Office Notes

Treating Physicians*

Date of Service/Condition*

Operative Report*

Office Notes

Treating Physicians*

Date of Service/Condition*

X-Rays (Films)*

Office Notes

Treating Physicians*

Date of Service/Condition*

Others*

Office Notes

Treating Physicians*

Date of Service/Condition*

For the purpose*

I would like to*

Pick up at the office (date specified below)

Mail or fax (location/fax number specified below)

Pick-up Date*

Full Name*

Address*

Phone Number*

Fax*

Additional Comments*

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