Medical Records and FMLA Form Completion Requests

Request­ing Med­ical Records

We have part­nered with MediCopy, a ful­ly HIPAA com­pli­ant health infor­ma­tion retrieval com­pa­ny, to ful­fill the Med­ical Records Requests of our patients. MediCopy adheres to all state and fed­er­al reg­u­la­tions con­cern­ing the release of med­ical information. 

A request to obtain copies of your med­ical record can be completed:

Online

• Com­plete the Autho­riza­tion for Release of Health Infor­ma­tion Form

By Paper Form

• If you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form 
• Sub­mit your com­plet­ed autho­riza­tion form to MediCopy by email­ing a copy to duly@​mrocorp.​com or by fax­ing to 833−734−1445. 

If you have any ques­tions, please con­tact MediCopy: 

Online Chat: MediCopy​.net | Phone: 866−587−6274 | Email: request@​medicopy.​net

Deliv­ery

Request­ed records will be mailed to the address spec­i­fied or sent elec­tron­i­cal­ly via encrypt­ed email, secure FTP, or requestor por­tals. Please indi­cate the pre­ferred deliv­ery method in Sec­tion 4 of the Autho­riza­tion for Release of Health Infor­ma­tion Form.

Please allow up to 30 days for processing.

Fees

There are no fees asso­ci­at­ed with requests for infor­ma­tion to be sent direct­ly to anoth­er med­ical provider out­side of Duly Health and Care. There is no fee to have med­ical records emailed to your­self. There may be fees asso­ci­at­ed for requests to be sent to you or to some­one who is not a med­ical provider. If there is a fee for your request, MediCopy will pro­vide you with an invoice sum­ma­riz­ing the charges. Pay­ments can be made online at MediCopy​.net, over the phone by call­ing 866−587−6274 or by mail­ing a check to the address list­ed on the invoice. Accept­ed forms of pay­ment are check or cred­it card. Cash pay­ments are not accept­ed. All fees are in accor­dance with Illi­nois and fed­er­al law. 

Learn more about MediCopy­’s Release of Infor­ma­tion Ser­vice.

Request­ing Form Completion

Please sub­mit your blank FMLA or dis­abil­i­ty paperwork:

Online

• Click here to sub­mit your blank FMLA or dis­abil­i­ty forms electronically.

By Paper Form

• If you pre­fer to sub­mit forms via email or fax, please down­load and com­plet­ed the Disability/​FMLA Intake Form & Autho­riza­tion and sub­mit it with your blank disability/​FMLA forms via email to dulyforms@​mrocorp.​com or fax to 888−496−8717.

Pay­ment

MediCopy will send you an invoice to be paid before the form(s) is com­plet­ed. The cost is $30 for the first form and $15 for each addi­tion­al form turned in at the same time.

Deliv­ery

Once pay­ment is received, MediCopy will com­plete your form(s) with­in three busi­ness days and release a copy to the des­ig­nat­ed request­ing party.

If you have any ques­tions, please con­tact MediCopy: 

Online Chat: MediCopy​.net | Phone: 866−587−6274 | Email: request@​medicopy.​net