Medical Records Request Form 

Questions? Call (843) 416-6130

A patient, or his/her legal representative, may review their medical records, obtain a copy of their medical records, or request to have copies of their medical records sent to another healthcare provider or facility. 

The Health Information Management (HIM) Department at East Cooper Medical Center fulfills requests for medical records.  Our staff will be happy to assist you in obtaining your medical records upon receipt of the East Cooper Medical Center HIPAA-compliant authorization form. 

Print the form and either mail, fax or personally deliver your completed and signed authorization to the HIM Department.

Our office hours are Monday through Friday 8:00 am- 4:30 p.m.
Fax 843-416-6805
Address 2000 Hospital Drive Mt. Pleasant, South Carolina 29464
Telephone (843)416-6130

Charleston Breast Center

Authorizations for medical records from the Charleston Breast Center can be submitted to:

Fax (843) 556-3844
Address 1930 Charlie Hall Blvd. Charleston, South Carolina 29414
Telephone (843)556-0166

Charleston Imaging Center

Authorizations for medical records from the Charleston Imaging Center can be submitted to:

Fax (843) 971-8832
Address 582 Lone Tree Drive, Mt. Pleasant, South Carolina 29464
Telephone (843) 352-0674

Medical Record Copy Charges

Fees will not be charged for records copied at the request of a health care provider (i.e. physician, nurse practitioner, nurse, etc.) or for records sent to a health care provider for the purpose of continuing care.  However, there is a charge for copying medical records requests such as for personal reasons and attorney requests.  In certain cases a $15.00 search and retrieval fee may apply. Requestors will be sent a prepayment invoice prior to the records being copied.

The charge is as follows:

Per page fee 1-30 pages  $0.65
Per page fee for 31 or more pages $0.50

Release of Information Services provided by IOD Incorporated.
Please note:  Incomplete/invalid authorizations will not be fulfilled. 

Elements of a valid authorization

The Health Insurance Portability and Accountability Act (HIPAA) call for certain elements must be contained and completed to meet the requirements of a valid authorization. These include:

  • Name and date of birth.
  • Statement of who is authorized to release medical records and who is authorized to receive the medical records
  • Purpose of disclosure
  • Type of information to be disclosed
  • Highly confidential information must be clearly marked or checked before it will be released
  • Statement of the right to revoke the authorization
  • Statement of patient’s right to refuse the release of medical records
  • Statement disclosed pursuant to the authorization may be subject to redisclosure
  • Statement patient treatment is not conditioned based on providing the authorization
  • Expiration date
  • Signature of patient or patient representative

Timeframe for receiving medical records

According to South Carolina Statue, Section 42-15-95, East Cooper Medical Center must comply with requests for medical records no later than 45 days from receipt of the request.  The HIM Department strives to complete all requests in 5 to 7 business days.  If you have any questions please contact the HIM Department at (843) 416-6130.