Request Medical Records

If you attended our facility and need medical records, we have made the process very easy for you. Under HIPAA, the federal law regarding medical information storage and access, you can request copies of your medical records from all your healthcare providers. We will do our best to complete your request as quickly as possible, but please allow 14-30 days of processing time.

If you are requesting a copy to be mailed or faxed, there is a fee of $35. This can be paid by check or with a credit card. Make sure to reference on the check or credit card payment that it is for medical records. Checks can be mailed to:

5319 Grand Blvd
New Port Richey, FL 34652

Medical Records Requirements:

Completed and signed request for medical records.

Download Form

Driver’s license or government-issued identification

If you would like to request your medical records, please send an email to: MedicalRecords@RocklandTreatmentCenter.com with all Medical Records Requirements as listed above or fill out the form below and upload your completed documents.

"*" indicates required fields

Your Name*

First Last

Client's Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

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Number of physical copies requested:

Price: $35.00

Total

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Upload completed request form here:

Drop files here or

Max. file size: 1 GB.

Rockland Treatment Center does not provide refunds of any monies paid by or on behalf of the client if the client leaves treatment against medical or clinical advice or is administratively discharged. Any incidental monies received and applied and or used will not be reimbursed if credit card was used to pay for said items. IF a credit card was used for payment of services offered at the center and a client leaves early due to an inadvertent situation, your stay will be pro-rated for your visit and any unused portion will be credited back through the credit card used to pay for said services whether it was your actual credit card or that of your friend, family or employer.

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Request Medical Records

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