Medical Record Release

To Request a Copy of Your Medical Record

To request a copy of your medical record, you must fill out and sign a release of information form.

Download the form below for a printable copy of the Medical Record Release Form and fax it to (401) 863-7953 or email it to Jennifer_Hodshon@brown.edu or mail it to Health Services at Brown University, Box 1928, Providence, RI 02912.

There is no charge for one or two page copies (e.g., immunization record, lab results); we can mail or FAX the information. We cannot FAX your entire medical record. If you want a copy of your entire medical record, there is a charge of 25 cents per page if there are more than twenty pages (the first twenty pages are free). Checks should be made payable to Brown University.

Always include the following information in a request for medical records (so that we can find your records):

  • your name;
  • Banner #;
  • complete current address and phone;
  • the last year you were at Brown.

 

 

Downloadable files:
.PDF file