Our patients care records are kept in strict confidence and in accordance with federal and state privacy regulations. The release of medical records requires a valid patient authorization or other processes, as required by law.
To obtain a copy of your medical record or information from it, complete and sign the Authorization for Release of Protected Health Information form and submit it to MedExpress’ Health Information Management Center by faxing it to 304-985-6804 or mailing it to 1751 Earl Core Road, Morgantown, WV 26505.
- Authorization for Release of Protected Health Information
- Spanish version of the Authorization for Release of Protected Health Information
Completing the request.
When completing the Authorization for Release of Protected Health Information request, please remember to:
- Complete all blanks. If not applicable, please note N/A.
- Clearly state who the patient is and the patient’s date of birth.
- Clearly state who is to receive the records, even if the patient will receive their own records, and where the records are to be sent.
- Specify dates of service for which records are requested.
- Confirm that the patient or legal representative has signed and dated the form.
- If acting as the legal representative, unless a parent, submit the document that empowers you as legal representative (examples: Medical Power of Attorney, Appointment as Guardian or Conservator).
- As needed, specify expiration date of the form, otherwise it shall expire in 6 months.
Please note: Incomplete authorizations are not valid and cannot be processed. Please be sure to complete all fields of the Authorization form.