Medical Record Release Form

Medical record form click here

Until 12/31/2021, we will supply up to the last 5 years of records on a CD free of charge if picked up. Otherwise, a charge of $5.00 per CD will apply for postage and handling, which will need to be paid prior to mailing. At this time we are only releasing/mailing the CD directly to patients.

Please be aware that most medical facilities do not require more than a few years of past records. Please verify with your new provider’s office their requirements.

Only the last 5 years of records will be supplied free of charge. Any records older than 5 years will incur a charge of 30 cents per page in compliance set forth by Oklahoma Statue Title 76 O.S. ยง 19; for electronic records (CD). If records older than 5 years are requested, please be aware it may take up to 30 days to process. An invoice will be generated once pages are counted and payment will be due before records will be generated.

Until 12/31/2021 please follow the below steps to obtain your medical records. After 12/31/2021, all records will be maintained by a record custodian. More information on their services and a link to their website will be provided closer to the end of December:

Please print, complete and sign the medical release form. This form will open in pdf printable format.

Please fax, email, mail, or drop off the completed form at the office

FAX
405-722-9463
EMAIL
NINA@PNFMC.COM
Mail or Drop Off
Putnam North Family Medical Center Medical Records
11220 N. Rockwell
Oklahoma City, Ok 73162