For a copy of your medical record, please complete our Authorization to Disclose Healthcare Information form.
Some helpful notes when completing the document:
- The section on Alcohol, Drug, and Substance abuse will need to be marked yes except when only requesting Lab Reports, Immunization Records, or Medication Records.
- If you are requesting the Psychiatric Evaluation, the section on Mental Health Records Dates will need to be marked yes.
- If you are unsure of the dates you were here, you may write in ALL or just the year. Incorrect dates will void the request and a new form will need to be completed.
- If you want your records via email, write the email address on the release.
- If you enter an authorization expiration date (bottom third of the release), please keep in mind processing time.
- We receive numerous requests and process them in the order they are received. By law we have 30 days to process a properly completed request.
By completing this form properly, we can ensure that we are releasing your confidential information to the right recipient.
Fax forms to 850-939-7278 or mail them to Twelve Oaks, Medical Records Dept, 2068 Health Care Dr, Navarre, FL 32566.
If you have any questions, please contact the Medical Records Department at 850-939-1200.