Medical Records

Medical Records

For medical records requests we require payment of a $25 processing fee for each file prior to processing (ref MO Rev Stat § 191.227).  *Please note that requests require seven (7) business days of processing time.

The following health information that relates to all services rendered at Brinton Vision may be released:

• Entire Medical Record including patient histories, office notes, test results, referrals, consults, and records sent by other healthcare providers.
• Patient History
• Office Notes
• Test Results
• Referrals
• Consults
• Records Sent by Other Health Care Providers

Patient Name

Date of Birth

Phone

Email

Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Recipient

Recipient Email

Recipient Phone

Fax Number, if applicable

Recipient Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Medical Records Request Payment

Price: $ 25.00

Card

Name on Card

Notes

Submit