OrthoAssociates - Centers for Orthopaedics

If you prefer to fax or mail the form, please download our form here

The Health Information Management (HIM) department is committed to maintaining your medical records and keeping your information private and secure in accordance with federal and state regulations and patient rights. For additional information regarding health records and privacy, please view our Notice of Privacy Practices.

How do I get a copy of my records?

While you have the right to access your information, the medical chart is the property of OA Centers for Orthopaedics (OA). If you were referred to OA by another provider, and shared that information with us, a copy of the initial office visit report will automatically be forwarded to him/her.

If you desire a copy of office visit documentation or images (x-rays and/or MRIs ordered by one of our providers) to be sent to yourself, or if you would like your records forwarded to another physician/medical provider, please fill out an Authorization to Release Protected Health Information form. A completed form is required for ALL such requests.

You may mail the completed form to:

OA Centers for Orthopaedics
HIM Department
33 Sewall Street
Portland, Maine 04102

OR

Fax the completed form to:

207-553-7168

If you do not have the ability to print the form, you may call our office (207-828-2209) and request that one be mailed to you.
Once we receive the completed form, requests are generally processed within 5 to 7 days.

Are requests processed at OA?
No. We partner with Sharecare Health Data Services.

Is there a change associated with your request for copies of records?
In accordance with State of Maine Statutes, there may be a “reasonable cost-based fee” If it is deemed that any processing fees apply, we will contact you before completing your request.

If you have an upcoming appointment with another physician/medical provider, someone from his/her office can contact us directly, as law allows us to release records to them without the need for you to complete a form.

** Please be advised that due to the high volume of requests for records, we are unable to accommodate “walk-in” requests.**

Patient Name (please print)*

First MI Last

Date of Birth

Telephone #:*

If we need to call you regarding this request, do we have your permission to leave a detailed message at the number provided above?*

Yes
No

As specified below, I hereby authorize OA Centers for Orthopaedics (OA), its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).

Address*

Name Street City or Town State Zip

Phone

How to Release:*

Mail as above
Email as above
Fax (X-rays/MRIs cannot be faxed)

Fax*

INFORMATION TO BE RELEASED (Select only those which apply)*

(Office Visit Notes/Operative Reports/MRI reports Information Box)( Specify dates (example – last 3 years), provider (example – Dr. Smith), body part (example – left hip), or can state “all.”)

(X-rays/MRIs on CD Information Box)( Specify dates (example – last 3 years), provider (example – Dr. Smith), body part (example – left hip), or can state “all.”)

other Specific Information

Purpose of release

Required*

I DO authorize disclosure of any information relating to alcohol and/or drug abuse treatment
I do NOT

Required*

I DO authorize disclosure of any information relating to treatment by a mental health professional or program
I do NOT

(Maine law requires our practice to inform you that, if this information is misused, disclosing your HIV infection status may have consequences, such as negative treatment in your personal life or by insurance companies. It can be important for providing you needed services and healthcare.)

My specific permission is required to disclose information regarding HIV Test Results or Status I understand that authorizing the release of such information does not confirm the existence of such history or treatment. Check one of the two options below and initial at end to confirm your choice

Required*

I DO authorize disclosure of information which refers to HIV test results, infection status, or treatment information
I DO NOT authorize disclosure of information which refers to HIV test results, infection status, or treatment information

I am not required to sign this form and that I may refuse to disclose all or some of the above healthcare information in my treatment records, but that refusal may result in improper diagnosis or treatment, denial of coverage for a claim for health benefits, denial of other insurance, or other adverse consequences. I understand that OA Centers for Orthopaedics will not condition treatment, payment, enrollment or eligibility for refusing to disclose information.
PHI released pursuant to this authorization may include records generated by another healthcare provider or facility.
I further understand that I may withdraw my authorization at any time except to the extent that action has been taken in reliance on this authorization. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Privacy Officer at OA Centers for Orthopaedics. I understand that revocation may be the basis for denial of health benefits or other insurance coverage or benefits. For additional details and information I may read OA’s Notice of Health Information Privacy Practices.
PHI used or disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by confidentiality laws.
A processing fee may be charged as permitted by law
I am entitled to a copy of this authorization, upon request.

This authorization becomes effective immediately and shall expire one year from the date of signing

Name of person signing:*

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