Skip to main content

Medical Records Release Form

As a patient of the UMSL Center for Eye Care, you have a right to your medical record. Please complete the Medical Records Release Form, sign it with an original signature, and submit it via fax to (314) 516-6405. The form may also be submitted to Cassidy Cooley, or sent via US Mail to the UMSL Patient Care Center, ATTN: Medical Records, 1 University Blvd, St. Louis, MO 63121. Be sure that your form includes the correct contact information for the party you wish to have your records released to.

Please note that medical records requests can take up to 30 days to fulfill; requests related to special reports (i.e., The Pupil Project) are subject to the completion and evaluation of recommended testing, and may take 12 weeks to fulfill. Records can be sent to whomever you designate, via fax, US Mail, or via UM Secure Transmit. Details regarding costs of records duplication and Secure Transmit are specified on the release form. There is no charge for records released to another healthcare provider, and there is no charge for a copy of the most recent patient exam. Other charges are based on the Missouri State Recommendations for Records Duplication. For questions, please contact the Compliance Specialist at (314) 516-6064.

Health Information Disclosure