Health Information Management Department

The Health Information Management Department is dedicated to the integrity and security of your private health information in accordance with state and federal regulations.

Health records are retained for a period of 10 years after your last date of service or final treatment. Patients have the right to review their health record, for an appointment please call (239) 624-6567. For a fee, patients can receive copies of their health record, however there is no fee when the records are sent directly to another healthcare provider for the purposes of continuity of care.

Obtaining a Copy of Your Medical Record

To obtain a copy of medical record information a Consent for Release of Medical Records form must be completed. The form is accessible online (click the link below) or by calling the Health Information Disclosure Management Department (239) 624-6567.

Instructions for Completion of a Consent for Release of Medical Records Form

Follow these instructions carefully when completing the consent for release form.  It is important that you read the release form and entirely complete it. Failure to do so could result in a delay to process this request to release your medical record information. A fee may apply for copies of records that are being sent to a third party other than a physician or other healthcare entity. Please see the Record Fees section below or all (239) 624-6567 with questions regarding fees.

Click for the Consent for Release Medical Records Form
  • Enter the patient name (maiden or former name, if applicable), full address, date of birth, telephone number and email address (if applicable).
  • In the next section check off the box to indicate if NCH Hospital records or NCH Physician Group records are to be released.   Please include the name of the physician(s) from the NCH Physician Group that you are requesting records from.   (If both hospital and physician group records are needed check off both boxes.)
  • In the next section, enter the name and address of the hospital, doctor, company or person to whom the information will be released.
  • In the Please Specify Media Type section, select how you would like the information released
  • The next section provides the option to refuse disclosure of sensitive information.   The types of sensitive information are explained in the statement on the consent form.  If you believe there may be sensitive information in your medical record that you do not want disclosed, please check off the Do Not release my sensitive information box.
  • Next check the box the best describes the Purpose for Release.
  • In the  This authorization is for the listed date(s) of treatment section, list the dates of service you want released.  If unsure of dates, use an approximate date range with a question mark (?) to indicate questionable date range.
  • In the Information to be released/disclosed section, check all boxes that apply.  If “Other” is selected, please be as specific as possible.
  • The patient, parent or legal/personal representative must date and sign the form.  (legal/personal representatives, please read the Patient Representatives Requesting Records section below. 

The completed consent for release form can be submitted in one of the following ways:

Patients can also come to the NCH Central Campus to complete the release form and/or pick up the records. Please note that a picture ID must be presented and that coming onsite does not guarantee that medical record copies can be obtained that same day.

Birth Certificates and Death Certificates are filed with the State of Florida. You may contact the County Clerk of Courts at (239) 774-8205 or the Bureau of Vital Statistics, Jacksonville, FL (904) 359-6900.

Record Fees

There is no charge for records that are requested for the purpose of continuity of care in which the records are sent directly to a physician’s office and/or medical facility, or for eligibility review with Medicare, Medicaid or other public assistance programs. There is a fee to the patient or the patient representative when the requested health record is not sent directly to a healthcare provider or public assistance program.

Non-continuity of care requests from any other party that is not the patient or the patient’s representative may be charged a fee.

Fees for copies of medical records are:

  • Flat fee of $6.50 per patient request
  • $.05 per page that are printed and delivered in hard copy 
  • Actual postage for records that are delivered in hard copy
  • $2.00 cost to deliver the portion of record maintained in paper for a standard request plus 6.5% sales tax and any applicable shipping and handling charges for medical records not sent DIRECTLY TO A PHYSICIAN OR HOSPITAL. Also, a fee of $6.50 per CD applies for Radiology, Cardiology and ECHO images.

Patient Representatives Requesting Records

Patient representatives must produce documentation proving legal guardianship and/or Power of Attorney for Health Care in order to request a copy of a medical record. The health record is a legal document that contains private health information. A spouse, children or significant others cannot request copies of a patient’s medical record without the patient’s written authorization unless they have legal authority to do so. Please note that a Power of Attorney for Health Care is no longer valid for patients that are deceased. A copy of a death certificate and/or executor to patient's estate documentation may be required when requesting a deceased patient's medical records.

If You Are Under 18

In general, a person under the age of 18 cannot consent to the release of his/her medical records except in one of the following exceptions:

  • Married, widowed, or divorced
  • Parent of a child
  • Members of the armed forces
  • Pregnant (or believes herself to be)
  • Living apart from parents and managing his/her own finances
  • Abortion records: records of unmarried minor who have received authorized consent from Superior Court for an abortion cannot be released without the minor’s written consent