Please allow up to 10 business days to process your medical records request.
Release/Receive Medical Records
- To Release your medical records or for TCC to request your medical records, please complete the Release of Information form found here. Receive-Release-of-Information-ROI-Revised-2.7.24.pdf (tricitycardiology.com)
- Print and fax, or email to referrals@tricitycardiology.com completed signed form.
- You may also request release form be sent to your email via DocuSign to electronically sign.
Forms Completion
- For Forms Completion (FMLA, Disability, 3rd party Life Insurance requests, Other), please fax 480-461-4243 with your request or drop off form to any clinic location. The request MUST include a completed and signed patient authorization form found here. Receive-Release-of-Information-ROI-Revised-2.7.24.pdf (tricitycardiology.com)
Medical Records Fees
- Records requested to be sent to another medical provider – no charge
- Records needed to apply for medical insurance – no charge
- Handicap placards (initial requests and renewals) – no charge
- Health records requested by patient less than 10 pages – no charge
- Health records requested by patient more than 10 pages – $25.00
- Single test (that may include more than 10 pages) – no charge
- Concentra DOT Medical Examiner Paperwork – no charge
- Imaging CD or jump drive -$25.00
- Forms – Disability, FMLA, FAA, Athletic Clearance & Physician Statement – $50
- Life Insurance 3rd party – $75.00
To speak to a medical records staff member, please all 480-835-6100 and select the medical records prompt.
See our website for all Forms here. Patient Information | Tri-City Cardiology of Phoenix, AZ (tricitycardiology.com)