Medical Record Request Information

Shady Grove Fertility has partnered with CIOX Health the nation’s largest provider of release of medical
information services, to process and fulfill your request for a copy of your medical record.

Due to the strict procedural and highly regulated steps involved in this process, known as the release of
information process, there are costs associated and, therefore, a fee for all patient requests for medical
records, based on state and federal law.

These rates are:

$6.50 Flat Fee + Sales Tax for an Electronic Copy of your Records
$0.12 per page + $0.90 Processing Fee + Sales Tax + Postage for a Mailed Copy of your Records

Per HIPAA regulations please allow up to 30 days from the date of receipt in the Medical Records Dept.
for your medical record request to be processed.

Due to HIPAA regulations release of information related to AIDS (Acquired Immunodeficiency Syndrome)
or HIV (Human Immunodeficiency Virus) Infection, genetic testing, psychiatric care and/or psychological
assessment, and treatment for alcohol and/or drug abuse can only be released with your consent
therefore you must initial if you require this information.

If requesting your records and your partner’s records please submit a separate medical record release
request form with separate email addresses.

Completed Medical Record Release can be faxed to 1-855-309-0287, dropped off at the front desk,
mailed to the address located on the form, or emailed to SGFmedicalrecords@sgfertility.com.
**Please note emailed requests are to submit record release forms only - it is an unmonitored
mailbox with an auto reply message. Please do not email to check the status of your requests.

Records delivered electronically will be sent from IOD Incorporated/CIOX Health. You will receive two
emails. Please check your junk/spam mail.

For Customer Service or Billing Inquiries please contact CIOX Health customer service: 1-800-367-1500.

© 2020 CIOX Health © 2020- SGF

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (PHI)
9600 Blackwell Rd., Suite 500, Rockville, Maryland 20850
Phone: 301-545-1417 Fax: 855-309-0287 Email: sgfmedicalrecords@sgfertility.com

_______________________________________ ____________________________
Patients Full Name (please print) Date of Birth (Mo/Day/Year)
_______________________________________ ____________________________
Street Address Social Security Number
_______________________________________ ____________________________
City, State, Zip Code Phone (Daytime)

At the request of the individual, I _____________________________, do hereby authorize Shady Grove Fertility
(Patient Name)
to release records for the time period dating from_____________ to ____________:

______ HISTORY & PHYSICAL _______ULTRASOUND REPORTS _______STIM GRIDS

______ PROGRESS NOTES _______LABORATORY REPORTS _______EMBRYOLOGY REPORTS
______ CONSULTATION NOTES _______RADIOLOGY REPORTS _______ENTIRE MEDICAL RECORD (includes all above-no US images)
______ OPERATIVE REPORTS _______PATHOLOGY REPORTS OTHER__________________________________________

_____ I DO ____ I DO NOT authorize release of HIPAA protected information related to AIDS or
(PLEASE INITIAL ONE ABOVE) HIV infection, sexually transmitted diseases, genetic testing, psychiatric care
and/or psychological assessment, and treatment for alcohol and/or drug abuse.

INFORMATION RELEASE TO: __________________________________________________

**Records can only be mailed to NAME of Company/Agent/Facility/Person
Physician’s office, not emailed. __________________________________________________
If a patient email address is provided Street Address
the records will SOLELY be sent __________________________________________________
via email. City, State, Zip Code
__________________________________________________
Phone Number

EMAIL DELIVERY: (PROVIDE EMAIL ADDRESS ONLY IF SELF/PATIENT IS RECIPIENT):

______________________________________________________________________________________________________________________

PURPOSE OF DISCLOSURE: ___________________________________________________________________________________

I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of
signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification
of cancellation. CIOX Health will not maintain the images beyond 30 days-subject to additional fees. I understand that the information used or
disclosed may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign
this authorization. My refusal to sign will not affect my ability to obtain treatment; or eligibility for benefits unless allowed by law. By signing below I
represent and warrant that I have authority to sign this document and authorized the use or disclosure of protected health information.

______________________________(By signing this form you are agreeing to the fee below) ______/______/_______
Signature of individual or guardian or Personal Representative of patient’s estate Date
NOTE: There is a charge of $6.50 flat fee for all records delivered electronically or $0.12 cents per page + $0.90
processing fee + tax + postage for records delivered via mail. CIOX Health has been contracted to provide this service and
will invoice you directly. Please do not send payment to SGF. Please allow up to 30 days for records to be processed.

For Customer Service or Billing Inquiries: CIOX Health 1-800-367-1500 02/2020-MDD