Frequently Asked Questions About Your Medical Record

How can I get a copy of my medical record?

To request a copy of your medical record, please complete our Authorization for Disclosure of Medical Information form. Complete all fields on the authorization form. If you do not know your medical record #, leave it blank. Sign and date the form. 

You may mail the form to Hattiesburg Clinic, Attn: ROIS, 415 South 28th Ave, Hattiesburg, MS 39401.  Include a check made payable to Hattiesburg Clinic for $20 as prepayment for medical record copies (see below for other charges).  In order to ensure privacy, we do not fax medical records.  However, you may fax your request form to ROIS at 601-268-5767.  If your request is faxed, full payment for medical record copies is required before obtaining records.

Our normal processing time for responding to requests for medical records is 5 -10 business days, depending on the availability of the medical record.

Download a printable authorization form in Adobe Acrobat© format.  Requires Adobe Acrobat©  Reader.

Who do I contact about copies of my medical record?

Please contact Release of Information at 601-261-3590 or 601-579-5276.  You may also contact Release of Information via email using our Contact Us form.

How much does it cost to get a copy of my medical record?

If medical records are being sent directly to another physician or healthcare facility, there is no charge.  If a patient is requesting a copy for their personal use, they must pay a $20 prepay for pages 1-20.  A fee of $1 per page is charged for pages 21-100 and $.50 per page for all pages thereafter.  If a patient requests a copy of the last visit only, lab only, or ancillary report done within a six month period, the fee is $1 per page.