Authorization Form (click here to print form)
As a patient of Tri-State Orthopaedics & Sports Medicine and/or Tri-State Physical Therapy, you are entitled to view and/or receive copies of your medical records. In an effort to facilitate this process, please download and complete our HIPAA compliant authorization form, which allows us to release information contained in your medical record. To Request Copies of your Medical Records:
- Please print the Authorization to Release Medical Records form.
- Complete this form in its entirety, including your name, date of birth and social security number. Please provide us with a detailed description of the information you are requesting as well as a complete mailing address and phone number for the individual(s) who will be receiving this information. Please provide an expiration date for this authorization. Make sure that you sign and date the authorization form.
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Completed authorizations can be submitted via:
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Mail:
Tri-State Orthopaedics & Sports Medicine, Inc.
Attn: Medical Records Department
5900 Corporate Drive, Suite 200
Pittsburgh, PA 15237
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Fax: (412) 367-9862,
attn: Medical Records Department
- E-Mail:Please scan your completed authorization with your signature and email as an attachment to medicalrecords@tristateortho.com.
Please be advised that we utilize a medical records copy service to handle the processing of all our medical records requests. Requests can take between 10-14 business days to process. Please contact the Medical Records Department at (412) 369-4000 Ext. 365 or email at medicalrecords@tristateortho.com with any questions. Thank you.
