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The “Authorization for Release of Health Information” can be mailed or you can personally deliver the request to the specific INTEGRIS facility where services were rendered. If you do not want your records mailed to you, please indicate on your authorization that you wish to pick up the records and indicate a daytime phone number to contact once the request has been completed.

•	Authorization for Release of Health Information Form
•	Autorización Para Divulgación De Información De Salud
•	GIAÁY CHO PHEÙP TIEÂU CHUAÅN CUÛA OKLAHOMA CHO SÖÛ DUÏNG HOAËC CHIA SEÛ THOÂNG TIN SÖÙC KHOÛE ÑÖÔÏC BAÛO VEÄ (PHI)

INTEGRIS Health releases copies of patient records upon request provided we receive a valid authorization signed by the patient or legal representative.

If picking up your requested records, please bring one of the following forms of identification and necessary documents (if applicable) to validate release of information:

Acceptable IDs Include:

• Driver's license

• Employment ID

• State Issue ID

• Current School ID

• Military ID

• VA ID

• Valid, Current Passport

Other documents as applicable:

• Power of attorney

• Legal guardianship papers

• Divorce Decree

• Death Certificate

In accordance to State Statute 76 o.s. 2001, section 19, INTEGRIS Health charges one dollar ($1.00) for the first page and fifty cents ($0.50) for each subsequent page copied from the medical record. The charge for copies of radiology films, photographs or other images shall not exceed five dollars ($5.00) or the actual cost of reproduction, whichever is less. The hospital will charge the requestor the actual cost of mailing the patient’s medical record copies.

Please allow 30 days from the date of discharge for record processing before requested copies will be available.

If you have any questions, please contact the specific INTEGRIS facility and ask for the Health Information Services Department or coordinator in charge of Health Information.