Records Request Form

Patient Request

You will need to complete a records release form. This form is available in person, electronically or by mail. Contact our Billing Office at (336) 703-2770 to receive this form. A copy of a valid government issued ID must accompany the request when mailed or emailed.

You may also pick up your records in person at: 911 E. 5th Street, Winston-Salem, NC 27101 (You will need to bring a current government issued photo ID)

Attorney Request

Attorney request are processed by our billing service, EMS Management & Consultants. These request are solely fulfilled via The fee for each record is $10. If you would like more information or a demonstration of the process, please contact their Legal department at 336-793-9887 Option 3.

Due to Health Insurance Portability and Accountability Act of 1996, Medical records can only be released to the patient, parents/guardians of minors, or others legally authorized to do so on behalf of the patient.