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.

Instructions:

  • 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 medicalrelease@mmclinic.com ,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