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Little Falls
320-631-7000
Pierz
320-468-2536
Randall
320-749-2877

Unity Family Healthcare Home

MY MEDICAL RECORDS

medical records

Family Medical Center is concerned about your privacy. To view, send or receive your medical records, call us at 320-631-7200. Security and identification vary with the nature of your request.

Your may use this Web site to authorize Family Medical Center to send your medical records to another approved health care provider. Complete the on-line form below.

Also, as a convenience prior to your visit, you may download, print and complete other forms pertaining to your medical records. Scroll down to the bottom of this page.

Medical record requests require one week to process.
If you place a request today, your records will be available on 5/26/12.

Online Records Request Form (pickup only):
Type of access requested:     Inspection of Records     Copy of Records

If copies are requested, please specify what copies are being requested as well as the specific time frames. The clinic's fees for copying records are listed below.

Doctor's office Notes
Last 5 years   All
Lab & X-ray reports
Last 5 years   All
Records of hospital inpatient and outpatient services
Last 5 years   All
Records of other services ordered/performed by Family Medical Center Physicians
Last 5 years   All
Copies of records which you have had forwarded from other hospitals or Physicians
Last 5 years   All
Copies of administrative reports/letters
Last 5 years   All
Copies of everything in the chart
Last 5 years   All
Other Records:
If the choices above do not allow you to adequately describe the information you want disclosed, please describe your request here:
At the time this policy is written, Minnesota statute provides that the Family Medical Center may charge a $15.05 retrieval fee, $1.15 per page copying fee, and sales tax for copying patient records. As a courtesy to our patients, we generally do not charge more than $10.00 per patient to retrieve and copy charts. When there are more than three persons in the family requesting records, we usually do not charge the family more than $25.00. Occasionally, we charge more when the number of pages to be copied per patient exceeds 25. We will contact you for prior approval if the fee will be more than $10.00 per individual or $25.00 per family.
Patient Name:   
Date of Birth:   
Name of requestor (if not the patient):   
Relationship to Patient:   
Contact Email:   
Contact Phone #:   
Comments or Instructions:
Other Record Request Forms:

 
 
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