PATIENT RECORDS

• Required documentation for request based on requestor:

1. Spouse – Healthcare Power of Attorney or Court-issued Letters of Administration & Death Certificate (if available) or This Form Notarized
2. Parent of Minor Child –Birth Certificate or This Form Notarized
3. Guardian – Court-issued Guardianship Papers or This Form Notarized
4. Executor/Administrator/Attorney in Fact – Court-issued Letters of Administration & Death Certificate (if available) or This Form Notarized
5. Patient’s Healthcare Power of Attorney – Copy of Healthcare Power of Attorney

 Requests for records can be submitted through one of the following:

• EMAIL to records@dos5.net
• FAX to 704-943-6001
• MAIL to 4425 Wilkinson Boulevard, Charlotte, NC 28028

If the appropriate paperwork is received, it can take up to 30 days to receive your requested records.

You have the option on the Patient Care Report Release Form to choose how you receive your requested records. If you do not indicate on the form how you want to receive the records, then they will be mailed to the address provided on the form.

It is important to provide a legible Patient Care Report Release Form, with accurate, updated information. This will ensure a smooth process from start to finish.

You can call 704-943-6000 or email us at Records@dos5.net

Note: Court, Regulatory Agencies, and Law Enforcement requests go to Legalrequest@dos5.net