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Release of Information
Request Records Electronically
CHI Lisbon Health now offers an online patient record request tool that verifies your identity by asking for a photo of your driver’s license, which can be taken via webcam or smartphone. Please note: Chrome, Safari and Firefox are the recommended browsers for this application. Below is the link that will launch the online tool to request medical records electronically:
Authorization for Use or Disclosure of Protected Health Information Access to Protected Health Information Form
In order to process your request for medical records, please complete all the fields on the ‘Authorization for Release of Information’ form below. Please pay careful attention to complete all areas of the form. If not completed, we may need to return your request for more information.
Patient Access Request to Their Protected Health Information
In order to process your request for medical records, please complete all the fields on the ‘Patient Access Request to Their Protected Health Information ’ form below. Please pay careful attention to complete all areas of the form. If not completed, we may need to return your request for more information.
Access Fees for PATIENTS ONLY:
The FIRST TWO PAGES are FREE and the remaining pages are billed as follows:
- Electronically maintained records delivered in electronic format $6.50
- Electronically maintained medical records combined with paper records delivered in Electronic format are billed at $6.50 (for the electronic portion) + $0.07 per page (for the paper portion) for labor involved in creating an electronic copy of the records maintained on paper
- Electronically maintained records delivered on paper are $0.90 for labor cost to create the paper copy of the record maintained electronically plus $0.05 per page for paper and toner
- Paper records delivered in electronic format are $0.07 per page for the labor involved in creating an electronic copy of the records
- Paper records delivered on paper are $0.12 per page
Plus, postage and applicable taxes
Please call (701) 683-6400 with questions about release of medical records or if you need assistance completing the authorization form.
Once you have completed and signed the form(s), utilize one of these options:
- Fax it to:
701-683-4345 - Mail it to:
CHI Lisbon Health
905 Main Street
Lisbon, ND 58054
Return it to the facility Registration Office and the authorization will be hand delivered to the HIM Department and your request processed.
Thank you,
CHI Lisbon Health HIM Department