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Patient Guide to Complete a Medical Record Request
A UMMC Release of Information Authorization form is located on the UMMC website. Go to this page: Request Medical Records and Images
You will be able to download and print a copy of the authorization form.
The Authorization for Release of Health Information must be completed, or it will not be accepted by UMMC. If this occurs, a correspondence letter will be sent to notify you of what is needed to complete your authorization.
Select the location (Jackson, Grenada, Lexington, or Other )
Patient Information – name, address, DOB, last four of SSN and phone no.
Release Information (To whom are you authorizing the records to be released to?) If you are the patient, please complete this section with the same information from Patient Information section. If you are requesting your records to be released to another facility (hospital, clinic, etc.), please include their complete address and fax number. If you are requesting your records to be released to a relative, attorney, insurance company, or other third party, please provide their complete information along with a phone number.
Purpose of Release – Please select one.
PHI to be Released – Format for Release – Please select one (Paper or Electronic). If you choose Electronic please provide an email address or write 'thumb drive' or 'storage media' on the right side of the authorization.
Service Dates and select the type of records you want released – Please complete a date range (for example: 01/01/2019 To 12/31/2019). Then select the type of records you want released (Example: Discharge Summary, Operative Report, Entire Medical Record).
Sensitive Information – Your initials are required if you are authorizing this information to be released.
Patient's Rights – Please read
Signature of Patient/Representative – Must be signed by the patient or the patient's representative (Parent of a minor child, legal guardian, spouse with a medical power of attorney, etc.)
Description – Are you the patient, parent, spouse, etc.
Date – Please provide the date you completed this form.
Important Note: In order to obtain your records, a legible copy of your photo ID must accompany your Release of Information Authorization form.
If a patient is unable to sign the authorization in the case of a deceased patient, please provide a death certificate and proof of kinship. (For example, if the deceased is a parent, a birth certificate of the son or daughter is needed. If the spouse is listed on the death certificate, then the spouse will only have to provide the death certificate and their photo ID.)
Once you have completed your Release of Information Authorization form, please submit your request using one of the following methods:
Mail to: University of MS Medical Center ATTN: Release of Information, 2500 North State Street, Jackson, MS 39216
Fax to: (601) 984-4044
There is a cost for the medical records; however, no money is required at the time of the request. After you have received the records, an invoice from CIOX Health will be sent to the address you provided. Please submit your payment at the time the invoice is received.
If you need assistance or would like to follow up on the status of your request, please call (601) 984-4050.