South Carolina Authorization For Release of Medical Information 2011South Carolina Authorization For Release of Medical Information 2011
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MIDLAN

MIDLANDS ORTHOPAEDICS, P.A
RELEASE OF MEDICAL INFORMATION PROTOCOL

Complete the Authorization for Release of Medical Information form in its entirety.
Mail the completed form to:

Or fax to: 803.933.6346

Midlands Orthopaedics, P.A.
Release of Information
1910 Blanding Street
Columbia, SC 29201
The form may also be dropped off at any of our locations.
Allow up to ten business days for the request to be processed.
In accordance with South Carolina Statute 44-115-80, you will be billed for the reproduction of
your medical records as outlined below:
$.65 per page for pages 1-30
$.50 per page for all other pages
Clerical fee not to exceed $15.00
Actual postage cost
Any questions concerning the status of your request should be submitted using one of the
following methods:
1. Patients may send a secure message by logging into the Patient Portal via our website,
www.midlandsortho.com. Click on the Patient Portal link. Log-in. Click “Send a message” to
submit a question.
2. Call 803-2