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Vaccine Administration Form

In order to simplify your vaccine visit, we encourage you to download, print and complete the vaccine administration form below. Please bring the completed form with you at the time of your visit.

Patient Medical Records Requests

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 Release of Information 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 form 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

If you are a third party and would like to request copies of a patient's medical record, please follow the instructions below.


  1. Complete all sections of the Request of Information Access 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 form 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

Q:
Can a patient review and/or receive copies of their own medical record?
A:
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.
Q:
How long are medical records kept?
A:
An electronic medical record is retained for each patient for ten (10) years following the last date of service.
Q:
Who is authorized to sign for release of medical records?
A:
The form must be signed by the patient or the parent or legal guardian of the minor whose medical records are being requested.
Q:
Who is authorized to sign for release of medical records if the patient is deceased?
A:
If a patient is deceased, the form 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.
Q:
How long does it take to receive requested information?
A:
There is a minimum of 4 business days (Monday - Friday 8am - 4pm CST) required from the time we receive the written request/form.
Q:
Can my doctor request my records?
A:
Yes, but only with a HIPAA compliant release form completed by the patient or physician.