Mailing or faxing to a physician a hospital or medical facility will be at no charge
Patients may make a request to have their medical record information forwarded to another medical facilities, such as a physician’s office, a health department or a hospital at no charge. The following is required prior to our department forwarding Protected Health Information:
- A completed Authorization for Use and Disclosure of Protected Health Information - English is required.
- A completed Authorization for Use and Disclosure of Protected Health Information - Spanish is required.
- Must have complete name, complete address to include street number and zip code, telephone number and fax number
- Our agency does not honor "Blank or Open Requests." The request must be specific as to the information that should be forwarded and the visit time frame should be specified.
- Patient's signature and/or authorized representative's signature is required on the bottom of the form, giving authorization for medical information to be faxed. It is not the policy of our agency to fax sensitive information pertaining to HIV, Communicable Disease and Family Planning unless authorized.
Mailing or faxing to an attorney, social security disability, insurance companies, etc. (fee required)
Request for medical record information sent to an attorney, social security disability, insurance companies, etc., will require a charge based on the number of pages copied. An invoice will be faxed to the appropriate requester for approval of payment. Payment must be remitted before records are disclosed. The following is required:
- Complete a Authorization for Use and Disclosure of Protected Health Information - English or Spanish version
- Must have complete name of facility, complete address to include street number and zip code, telephone number and fax number.
- Our agency does not honor "Blank or Open Requests." The request must be specific as to the type of information requested and the time frame specified.
- Patient's signature and/or authorized representative's signature is required on the bottom of the form, giving authorization for medical information to be faxed. It is not the policy of our agency to fax sensitive information pertaining to HIV, Communicable Disease and Family Planning unless authorized.
Record requests are usually processed within 7 to 10 business days.
Mail or fax request to:
Cumberland County Department of Public Health
Attn: Medical and Vital Records Support Division
1235 Ramsey Street
Fayetteville, North Carolina 28301
910-433-3895 |