The Health Insurance Portability and Accountability Act (HIPAA) has set rules for health care to protect and guard your health information. MMC is dedicated to upholding this with integrity!

A release of information (ROI) may be used for any of the following:

1. To submit to another facility or doctor's office

2. To obtain a cop yof their own records

3. A copy has been requested by another doctor's office, and the patient is requesting information be sent

** Please note if you are an insurance company, record retrieval company, or an attorney's office.Please do not email any requests, but call our records department for procedures and prepayment information.


  • Please print the document titled "HIPAA Release Form" under the downloads tab. 
  • Complete the form using first and last name of doctor or facility, name and phone, and/or fax numbers to which this information is to be disclosed.
  • Form must be signed by the patient, unless the patient is a minor. If so, the legal parent must sign (non legal guardians will not be acceptable). POA's will be accepted if the document is appropriate and in the patient's chart.
  • Please scan in your document once completed, and email to ,or fax to 615-867-7926.

Please feel free to contact the Records Release phone number for any further questions at 615-867-7917. Thank you!

Murfreesboro Medical Clinic | 615-893-4480 | click here for locations