Medical Records Requests

At Piedmont Healthcare, we are dedicated to your health and well-being. We're also strong advocates for patient privacy. The notices below explain the strict conditions under which your medical information may be distributed to other organizations, and how you can send your medical records to other doctors or hospitals.

By completing this form, we can send your medical records to a physician, another hospital or provide them for you.

Download the Request for Medical Records form below. A copy of your government ID is required.

Request Form (English)   Request Form (Spanish)


You may fax or email your completed request form and ID to  In the subject line of your email, please type in the hospital name where you are directing the request form. Use these tips to avoid unnecessary delays:

  • Proofread your form to assure all applicable blank spaces are completed and boxes checked before you email the completed form and ID.
  • For a method of disclosure, you may check the box for Mail, Secure Email Portal,  or pick up at location. Please check only ONE box.
  • Make sure the applicable dates of service are entered.
  • Most important, please enter the hospital name in the subject line of your email where you are directing your request.
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