FORMS & Medical records
To submit your request, download, complete and submit the following form to The Clinic @ Central Oklahoma Family Medical Center. You can either mail OR fax the completed form. For more information, please fill out the form on our
contact page.
Mail completed form to:
Health Information Management Department
905 Colony Drive
Ada, Ok 74820
Fax completed form to:
580.279.1994
Email completed form to:
Patient Portal & Registration Forms
Pharmacy Requests
Income Guidelines
Disclaimer
Release of Information
The Clinic releases copies of patient records upon request provided we receive a written request or valid authorization signed by the patient or legal representative. You may give this authorization by downloading a copy of our medical records release form or receiving a copy at one of our locations.
To submit the authorization, please email a copy to HIM-ROI@cofmc.org or return the signed authorization to one of our locations. Utilizing either method, please specify the health information being requested and provide current contact information including patient name, your name, phone number, and email address. For security purposes, if possible, we will provide a copy of your records to you in the patient portal. Otherwise, we will arrange to provide records in another compliant and acceptable format. For questions, please contact Health Information Management at HIM-ROI@cofmc.org for any questions related to your release of information. If picking up the requested records in person, please provide a photo ID to our front desk representative.
Medical record copy fees may be applied as below pursuant to federal regulation 45 CFR 164.524(c)(4).