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Medical Records Release Form

If you are requesting medical records for yourself or a patient under your care, you must fill out an Authorization to Release Protected Health Information form.

You may obtain this form from either Arkansas Allergy & Asthma Clinic location or download the form to print and complete below:

Click here to download the Authorization to Release Protected Health Information form.

Where to Return the Form

Once you have completed the form, please return it using one of the following options:

Deliver to any Arkansas Allergy & Asthma Clinic location during business hours.
Click here for office locations and hours

Mail:
Arkansas Allergy & Asthma Clinic
Attn: Medical Records
9800 Shelbyville Rd. #220
Louisville, KY 40223

Fax: 502.429.6157, Attn: Medical Records

Email: medrec@familyallergy.com
This email address is strictly for medical record release forms, and any other emails will not be responded to. For other questions, please call us.  

Please Note

  • Medical records requests are completed in the order that they are received.
  • Although we are allowed 30 days by law to process records requests, we do our best to complete them in a timely manner.
  • Patients are entitled to ONE free copy of their medical records. Any additional requests for records are charged at a rate of $1.00 per page.
  • All medical records are processed at our main office located at 9800 Shelbyville Rd. #220, Louisville, KY 40223.
  • If you are requesting medical records for more than one patient (i.e. you and your child), you must fill out separate forms for each patient.
  • Due to required verification, we cannot accept electronic signatures for medical record requests. 

Healthcare Provider Requesting Documents

If another healthcare provider is requesting your medical records from our facility for continuing care, you DO NOT need to fill out a medical records request form. Please contact that healthcare provider and request that they fax their cover sheet with:

  • Patient’s name
  • Patient’s date of birth
  • If applicable, date of Patient’s appointment with that provider
  • Specific records needed

Should you have any questions, please contact Arkansas Allergy & Asthma Clinic Medical Records at 502.429.8585 x1010 or 1.501.227.5210 x1010.