Medical Records Policy | Arboretum OB/GYN

At Arboretum Obstetrics and Gynecology our staff is happy to coordinate and process any medical record request and short term disability claims that our physicians determine are appropriate. Once an Arboretum Obstetrics and Gynecology physician has approved your request, a medical records release or disability claim form must be completed. Our practice is happy to provide you with a medical record release via our website or in our office. All disability claim forms must be provided by your employer or the requesting entity. All disability forms and medical record requests will be completed in two business days of the initial request. In addition, due to the increase in disability and medical record requests, we have implemented the following financial policies:

Medical Record Release to another physician office- No cost
Medical Record Release to patient- Pages 1-4, $2/page, Pages 5+ $10 per chart
Medical Record Release to insurance company- $35
Medical Record Release to attorneys- $10
Disability Form- $10 per completed form

Please feel free to call our office at (704) 341-1103 and speak with our medical records personnel. We look forward to assisting you with your medical records needs!

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Please take the time to complete our Medical Records Policy Form below.This form is secure and all information is encrypted to protect your personal information.

PERSONAL INFORMATION

First Name*

Last Name*

Birth Date*

Address*

City*

State*

Zip*

AUTHORIZATION

Yes I authorize Arboretum Obstetrics & Gynecology to obtain my records from:

Name

Telephone Number

Fax Number

Address:

Yes I authorize Arboretum Obstetrics & Gynecology to release my records to:

Name

Telephone Number

Fax Number

Address:

NOTICE TO TRANSFERRING PATIENTS:

In an effort to improve our customer service, please provide your reason for transfer:*

This form hereby releases the sender from all legal responsibility or liability of the release of information described above from my records. Disclosure of this information without written consent by me is prohibited by federal law.

I understand that I may revoke this consent at any time. I also understand that this authorization shall expire without express revocation, three months from the date below.

Patient Signature
(Please type your name):*

Date*

Convenient

Location

Arboretum Office

3125 Springbank Ln.

Suite B

Charlotte, NC 28226

(704) 341-1103

Or email us at info@arboretumobgyn.com or call our office at 704-341-1103 and ask for access to the patient portal to electronically communicate with us!