For Patients Requesting Their Records:
Click on the button below to print the Release of Information form. It is very important that you complete each section of the entire form, sign and date. Please fax or mail your completed and signed ROI form, along with a copy of your photo ID to the address or fax number below, or you may bring it in to any of our office locations.
IF YOUR REQUEST INCLUDES 10 PAGES OR MORE OF YOUR PROTECTED HEALTH INFORMATION, YOU WILL BE CHARGED $6.50.
IF YOUR REQUEST FOR RECORDS IS OVER 10 PAGES OR MORE YOUR RECORDS WILL BE PUT ON A CD. IF YOU ARE REQUESTING PAPER COPIES, THERE WILL BE A CHARGE PER PAGE FOR ANYTHING OVER 100 PAGES.
If your request includes mammogram films please contact our office directly at 260-432-4400. By law we have 30 days after the receipt of the request to release medical records. Our mailing address is as follows:
Associated Surgeons and Physicians
2518 E. Dupont Rd.
Fort Wayne, IN 46825
FAX (260) 969-6898
For All Other Parties Requesting Records:
Print, complete and fax the online form or you may also use your own records request form and fax to the above listed number. If you have a single request or your patient is already in office, please feel free to contact us directly.
*Please allow 5 to 10 business days to process your request.