Medical Records
Fees: All records for a requesting physician are free but must be requested by the physician's office. Processing time for requesting physician is done immediately.
Fees: Records for personal use, attorneys and/or insurance is $25.00 for the first 20 pages, then $0.50 per additional page and actual postage if not faxed or picked up. Processing time may take up to 10 days. To expedite a records request, there is an additional $10.00.
To insure patient confidentiality is protected at all times, "release of information" forms must be signed by patient prior to the release of information to another physician, attorneys, insurance companies or patient.
Authorization Forms Required for Release
Release Form 1: Sender or RecipientThis form allows your medical records to be released to or from designated parties to or from Mark D. Le, M.D., P.A. medical clinic.
Agreement to Pay Form
This form must be filled out and included with Release Form 1
(Not required if records are being sent to another physician.)
Release Form 2: Release for a Minor
This form must be completed along with the standard HIPPA for releases involving records of a minor.
Release Form 3: Release for a Deceased Patient
This form must be completed along with the standard HIPPA for releases involving records of a deceased patient.
Permission to Share Limited Health Information
This form allows your medical information or limited medical information to be shared with designated person(s) authorized by you.