Medical Records Request

Med­ical Records > 

Form Com­ple­tion > 

We have part­nered with MediCopy, a ful­ly HIPAA com­pli­ant health infor­ma­tion retrieval com­pa­ny, to ful­fill the Med­ical Records Requests of our patients and to com­plete FMLA and dis­abil­i­ty forms. MediCopy adheres to all state and fed­er­al reg­u­la­tions con­cern­ing the release of med­ical information.

Request­ing Med­ical Records

Please note that some of the infor­ma­tion you are request­ing may be avail­able online in our patient por­tal, MyChart, under the Shar­ing Hub section. 

A request to obtain copies of your med­ical record can be completed:

Online

• Com­plete the Autho­riza­tion for Release of Health Infor­ma­tion Form

By Paper Form

• If you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form.
• Sub­mit your com­plet­ed autho­riza­tion form to MediCopy by email­ing a copy to qmg@​mrocorp.​com or by fax­ing to 833−416−9133 (This fax num­ber only accepts release of infor­ma­tion forms. Med­ical records and oth­er cor­re­spon­dence will not be accept­ed). 

Deliv­ery

Request­ed records will be mailed to the address spec­i­fied or sent elec­tron­i­cal­ly via encrypt­ed email, secure FTP, or requestor por­tals. Please indi­cate the pre­ferred deliv­ery method in Sec­tion 4 of the Autho­riza­tion for Release of Health Infor­ma­tion Form. Please allow up to 30 days for processing.

Fees

There are no fees asso­ci­at­ed with requests for infor­ma­tion to be sent direct­ly to anoth­er med­ical provider out­side of Quin­cy Med­ical Group or to have med­ical records emailed to yourself.

Learn more about MediCopy­’s Release of Infor­ma­tion Ser­vice.

Request­ing Forms Completion

Please sub­mit your blank FMLA or dis­abil­i­ty paperwork:

Online

• Sub­mit your blank FMLA/​Disability forms electronically.

By Paper Form

• If you pre­fer to sub­mit forms via email or fax, please either com­plete this online form or down­load and com­plet­ed the Disability/​FMLA Intake Form and Autho­riza­tion on paper and sub­mit it with your blank disability/​FMLA forms via email to qmgforms@​mrocorp.​com or by fax­ing to 888−824−8074 (This fax num­ber only accepts autho­riza­tion forms, includ­ing release of infor­ma­tion and disability/​FMLA requests. Med­ical records and oth­er cor­re­spon­dence will not be accept­ed). 

Fees

MediCopy will send you an invoice to be paid before the form(s) is com­plet­ed. The cost is $30 for the first form and $15 for each addi­tion­al form turned in at the same time. Pay­ments can be made online at MediCopy​.net, over the phone by call­ing 866−587−6274 or by mail­ing a check to the address list­ed on the invoice. Accept­ed forms of pay­ment are check or cred­it card. Cash pay­ments are not accept­ed. All fees are in accor­dance with Illi­nois and fed­er­al law.

Deliv­ery

Once pay­ment is received, MediCopy will com­plete your form(s) with­in three busi­ness days and release a copy to the des­ig­nat­ed request­ing party. 

If you have any ques­tions, please con­tact MediCopy: 

online chat: MediCopy​.net | phone: 866−587−6274