Release of Information Form Instructions

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855-925-4733

 

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Release of Information Form

To transfer or request copies of your personal medical record, please follow the instructions below. To release medical records, you must be 18 years of age or older or be the parent or legal guardian of the minor whose medical records you are requesting.

  1. Complete all sections of the form.
  2. Include the completed address of where you would like your records sent.
  3. Be as specific as possible about the information that you'd like released (e.g. specific dates of service, specific treatment, immunization records, etc.)
  4. Please mail or fax your authorization and copy of your Photo ID to:

Release of Information
Take Care Health Services
P.O. Box 691569
Orlando, FL 32819

-Or-

Fax to: 888-297-8357
Attention: PSC - ROI Department

Frequently Asked Questions

Can a patient review and/or receive copies of their own medical record?

Under normal circumstances, patients have a reasonable right to access their own medical records. All requests by the patient for copies must be received in writing.

How long are medical records kept?

An electronic medical record is retained for each patient for ten (10) years following the last date of service.

Who is authorized to sign for release of medical records?

The authorization must be signed by the patient or the parent or legal guardian of the minor whose medical records are being requested.

Who is authorized to sign for release of medical records if the patient is deceased?

If a patient is deceased, the authorization must be signed by the appointed personal representative. Otherwise, the surviving spouse, an adult child, a parent or responsible next of kin may authorize release of records.

How long does it take to receive requested information?

There is a minimum of 4 business days (Monday - Friday 8am - 4pm CST) required from the time we receive the written request/authorization.

Can my doctor request my records?

Yes, but only with a HIPAA compliant release form completed by the patient or physician.

Patient care services at Healthcare Clinic at select Walgreens provided by Take Care Health Services, an independently owned professional corporation whose licensed healthcare professionals are not employed by or agents of Walgreen Co., or its subsidiaries, including Take Care Health Systems, LLC. Walgreen Co. and its subsidiary, Take Care Health System, LLC, provide management services to in-store clinics and provider practices. Privacy Practices