Medical Records Request

Instructions for Requesting Medical Records

Life Solutions South has a process for clients or their personal representative for requesting in writing:

• Copies of their medical record
• That their medical record be sent to another individual or entity

For requesting a copy of your Medical Record:
Read carefully the form “Medical Records Request”. Complete the top section ONLY. It is essential that you list your current and accurate contact information and check all applicable boxes.

Submission Methods: You may submit this form in person or mail it to the clinic where you receive services.

Fees:

• A flat fee of $5.00 (for labor and supplies) is charged for paper copies and postage, if mailed.
• A flat fee of $6.50 is charged for electronic requests.
• A flat fee of $10.00 is charged for a treatment summary along with postage, if mailed.

For requesting a copy of your Medical Record to be sent to another individual, entity, or other healthcare provider:
Complete the form “Authorization for Use and Disclosure of Protected Information”. Please ensure that all necessary information is provided along with signature(s) and date(s) for Life Solutions South to process your request.

Submission Methods:

• You may submit this form in person to the clinic where you receive services.
• Mail form to:
  • Life Solutions South
    Attn: Medical Record Release
    2728 Euclid Ave. Suite 400
    Cleveland, OH 44115
• Fax it to 216-600-5197

Fees:

• Reasonable, cost-based charges will apply according to applicable statutes and Life Solutions South policies.
• There is no charge for sending your medical records to another healthcare provider.

Please note: Only complete forms with valid consents will be processed in accordance with applicable laws and Life Solutions South’s policies.

For questions regarding record releases, you may call 216-236-3028 and ask to speak to a Record Releases Associate.