Medical Records Requests

To request copies of medical records for a patient, client, or resident from Ecumen, please complete this form. Submitting this form initiates the request process. To proceed, Ecumen must have a copy of the legal authority to release the records (e.g., Health Care directive, Power of Attorney, Release of Information, Guardianship documentation, etc.) 


Once Ecumen receives both the completed request for information and necessary legal documentation, Ecumen will respond within 30 days to provide the requested records.


Please note that, in accordance with State and Federal Regulations, Ecumen may charge fees for certain record requests. If a fee applies, you will be notified before processing begins. 


Please fill out all relevant and required information below. Incomplete forms will not be processed. If additional information is needed to process your request, Ecumen will contact you.

 
 
 
 
Phone
 
 
 
 
mm/dd/yyyy
 
 
 

Select ALL items that apply


*Starred items requested will require a separate request of information to release

 

Select all that apply

 
 
 

Complete this field IF the request was received on a date different than today. (ex: received medical record request via US Mail)

 
mm/dd/yyyy
 

Please attach documentation of your legal authority to receive health information. (ex: POA, Guardianship, Conservatorship, Completed ROI, Healthcare Directive)

Drop your files here
 

By submitting this form, I/We understand the following:


Health information is protected under State and Federal confidentiality and data privacy regulations and cannot be disclosed without applying appropriate legal written consent unless otherwise provided for in the regulations.


Ecumen cannot prevent re-disclosure of protected health information by the person or organization receiving the requested records under this authorization, and that information may not be covered by State and Federal privacy protections after it is released.


Ecumen has 30 days from the date this written request and necessary legal authority is received to provide the requested records and that I/we will be contacted before disclosure if a fee is applied to the records request.