HIPAA Medical Release Form

Provider/Medical Practice/Hospital

Patient Information

Medical Release
Continued Medical Care
Legal Purposes
Insurance Purposes
Personal Interest
Other:
Yes
No

Please Upload a Government-Issued Photo Identification (State Driver's License, State Issued Non-Driver's License, Passport, Military ID) or alternatively enter the last four digits of your social security number. For Third Party Request please upload the legal documentation requesting the records.*

OR

In order for us to disclose protected health information related to reproductive health care, the DHHS requires a completed attestation form. Please download, complete, and upload the form below *

HHS OCR Modal Attestation form Reproductive Health care use of Attestation

In accordance with HIPAA Privacy Rule 45 CFR § 164.524 , Morgan Records utilizes the “average cost” pricing method. Please note. This is not to be confused with charging a “flat fee” which is NOT how we set pricing. The fees cover our labor, supplies, and postage costs and ensures reasonable, compliant charges that offer the best value for all requesters.

Secure HIPAA Electronic Transfer    
USB Thumb Drive mailed to Home or Physician    
Attention*
Company/Provider
Address Line 1*
Address Line 2
City Name*
State*
Zip*

You have selected to pick up your medical records. Once your records are processed we will contact you to set up a pick up time.

We are located at:
Morgan Records Management
8 State Street
Nashua, NH 03063

Request Summary

Request Quantity Total Actions

Signature*

Patients over the age of 18 must sign the release form. If a patient is unable to sign that is over the age of 18 please contact medical@morganrm.com or 833-888-0061 on how to proceed.

Do not sign this electronic form if you are not the patient.

I am the patient or legal guardian who has authorization to release the above records. Any facsimile, copy, or photocopy of this release will be valid for 90 days and shall authorize you to forward my medical records. This form gives you permission to share my private information obtained from this facility. Only records from this facility can be legally released. Any records from other physicians must be obtained from them directly.

I understand that the medical record released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above.

Your files will be processed in the order they have been received and will be delivered based upon your delivery selection within 30 business days.

Please check your spam folder for records and other correspondence from us.

Note: * indicates a required field

Payment Information

Submit Request Now and Pay with Credit Card
Morgan Records Management LLC adheres to strict industry standards for payment processing, including:
  • 128-bit Secure Sockets Layer (SSL) technology for secure Internet Protocol (IP) transactions.
  • Industry leading encryption hardware and software methods and security protocols to protect customer information.
  • Compliance with the Payment Card Industry Data Security Standard (PCI DSS).
For additional information regarding the privacy of your sensitive cardholder data, please read the Privacy Policy.
Submit Request Now and Please Invoice Me

Invoice

Please provide the responsible parties email address, so an electronic invoice may be sent.

Email Address to Send Invoice:
Attn: Morgan Records Management
8 State Street
Nashua, NH 03063

Please note this option does not submit the request and the completed form and payment must be sent to the above address. Checks made payable to Morgan Records Management


Order Summary