How may I reuest a copy of my medical record?

For any purpose other than treatment, payment, or operations in order to receive a copy of your Protected Health Information (PHI) you must complete an Authorization For Disclosure of Medical Information form. Upon completion of the form, send the form either by fax at 423-567-4722 or by mailing it to:

Neighborhood Urgent Care

Attn: Medical Records

P.O. Box 787

Jacksboro, TN 37757

Who may sign the authorization?

The patient must sign providing authorization to release their medical records unless:

1. The patient is a minor in which case their parent or legal guardian may sign.


2. The patient is deemed mentally incompetent. Then their legal guardian may sign the authorization along with sending a copy of the Durable Power of Attorney with the authorization.


3. The patient is deceased in which case the executor of the estate or surviving spouse may sign the authorization. Please send a copy of the death certificate with the signed authorization.

What is the cost for a copy of my medical record?

There is a cost associated with obtaining a copy of your medical record. Please complete the Patient Fees Agreement and mail or fax along with your authorization. You will receive a call with the cost to copy your medical record. You may pay this with a credit card at that time.

How may my physician request a copy of my medical record?

Your doctor may call the records department at (423) 437-8767, or fax a request to (423) 567-4722.