Patient Care Report Release Form
To assist with your request for records, we have answered some of the most commonly asked questions here:
How do I request records?
You request records by completing the Patient Care Report Release Form. If you are requesting a record and you are not the patient, you must provide the applicable “Required Documentation” (below), or complete the Notarization page attached to the Patient Care Report Release Form. We ask that a valid photo ID be included with all requests.
- Required documentation for request based on requestor:
- Spouse – Healthcare Power of Attorney or Court-issued Letters of Administration & Death Certificate (if available) or This Form Notarized
- Parent of Minor Child –Birth Certificate or This Form Notarized
- Guardian – Court-issued Guardianship Papers or This Form Notarized
- Executor/Administrator/Attorney in Fact – Court-issued Letters of Administration & Death Certificate (if available) or This Form Notarized
- Patient’s Healthcare Power of Attorney – Copy of Healthcare Power of Attorney
Requests for records can be submitted through one of the following:
- EMAIL to firstname.lastname@example.org
- FAX to 704-943-6001
- MAIL to 4425 Wilkinson Boulevard, Charlotte, NC 28028
How long will it take me to receive my requested records?
If the appropriate paperwork is received, it can take up to 30 days to receive your requested records.
How do I get my records after I make the request?
You have the option on the Patient Care Report Release Form to choose how you receive your requested records. If you do not indicate on the form how you want to receive the records, then they will be mailed to the address provided on the form.
It is important to provide a legible Patient Care Report Release Form, with accurate, updated information. This will ensure a smooth process from start to finish.
What If I have questions about my request?
You can call 704-943-6000 or email us at Records@medic911.com
Note: Court, Regulatory Agencies, and Law Enforcement requests go to Legalrequest@medic911.com