Instruction for request of Protected Health Information (PHI)
CONSENT FORMS
Release to a Physician
Please fill out and sign the consent form if you would like Gastroenterology Assoc. of Cleveland Inc. to send your medical records, Protected Health Information (PHI), to your Physician.
Release to Patient
Please fill out and sign the consent form if you would like Gastroenterology Assoc. of Cleveland Inc. to send your medical records, Protected Health Information (PHI), to yourself (patient).
Please e-mail consent form to GastroAssocPHI@gmail.com
*Processing Fees
Please make a check of $35 payable to Gastroenterology Assoc. of Cleve., if you request to release your PHI to your Physician.
Please make a check of $50 payable to Gastroenterology Assoc. of Cleve., if you request a personal copy of your PHI to be sent to yourself (patient).
Additional charges may be assessed for USPS postage.
Please mail a copy of the consent form and the check to:
Gastro PHI
18575 Parkland Drive
Cleveland, Ohio 44122
NOTE: No request will be initiated and processed until a check is received along with the appropriate signed consent.
Expected Date
Please Allow 30 days for a copy of your medical records, PHI, to be fully processed and sent. We will contact you if your consent form is not complete. This may cause delays in processing and sending.
* The charges will help defray only part of the cost for the storage and retrieval of your records in a local secure facility. A trained employee will retrieve your record, break down the chart, copy the records, fax or hard copy the records for mailing, reorganize the chart and accurately have it refiled. The cost of the fax and copy machines and the supplies including paper, ink and maintenance are included. A secure record will be kept of each request, with the date requested and where the record was sent and by what means.