“Dr. Runk coming into my life and taking care of me was meant to be. She’s definitely the reason that I’m still here with my family today.”
— Kelly R.
Forms
Click to view or download the forms below.
*An Important Note About the Authorization for the Release of Medical Records Form
We have partnered with MediCopy to fulfill your Release of Information requests. MediCopy is fully HIPAA compliant and adheres to all state and federal regulations concerning release of medical information. To request your medical records please fill out the Authorization for the Release of Medical Records form on this page.
Patients can request copies of their medical records at no cost, but delivery fees apply for postage! Please provide an email address on the authorization to expedite the process and delivery method. Records sent via email or to another provider are complimentary. Requests are completed within two (2) business days after receipt by MediCopy.
If you have any questions, please contact MediCopy: Online Chat: MediCopy.net | Phone: 866-587-6274 | Email: [email protected]. Learn more about MediCopy’s Release of Information service
- Authorization for the Release of Medical Records - Complete Online View
- New Patient Registration & Consent Form Print
- Established Patient Update Form Print
- Authorization to Release Protected Health Information Print | En Español
- Notice of Privacy Practices Print
- Patient Request for Access to Health Record Print
- Mammography Records Release Form – Online Version View
- Mammography Records Release Form – Print Version Print
