NOTICE OF CHARGES FOR MEDICAL RECORDS

Please be advised that the following rates apply for records requested by the patient for Personal Use and/or Transfer only.

All rates are established by the Ohio Revised Code 3701.74 and are in accordance with HIPAA regulations as they pertain to charges for release of information.

The rates are as follows and are effective as of January, 2011:

• $ 2.88 Per pages 1 – 10 (first 10 pages)
• $ 0.60 Per page 11 – 50
• $ 0.24 for each additional page (pages 51 and up)
• The actual cost of any related postage incurred by the health care provider or medical records company.

Columbus OB-GYN processes all requests and bills for the medical records.

Columbus OB-GYN will forward up to two years of medical history, unless the patient requests in writing that more records should be sent. Please allow adequate time for medical records to be processed and mailed to the specified address. You will receive an invoice from Columbus OB-GYN for services rendered.

If you do not want your records processed, please contact us within 14 days of the date of this letter. Otherwise, we will process your request and submit an invoice to you for payment.

Please direct any questions to us at (614) 434-2400 or toll free at 1-800-259-8948, Medical Records Department.

To request a copy of your records please complete, print and mail this Medical Records Request Form.