PHI Authorization Form

For records being transferred to another physician there is not a charge.

For records being released into the patient's custody MPMPC applies the following formula:

$1.00 per page up to twenty-five pages.

.25 cents per page for each page greater than twenty-five.

Related Documents:

PHI Auth Form Revised 0909.pdf
This is your authorization to request or release your medical records. Download and complete this form. Return it to your provider's office location for processing.