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Medical Records Request

To receive your medical records, you must complete the Authorization for Use or Disclosure of Protected Health Information form.  Requests may be submitted by mail or fax to Sampson Regional Medical Center's Health Information Department. If the patient is under 18 years of age the authorization form must be completed by a parent of the minor.  

Download the medical record request form using the link below.  Once you have completed and signed the form (no typed signatures), choose one of the following ways to send your request to Sampson Regional Medical Center's Health Information Department.

Authorization for Use or Disclosure of Protected Health Information

Fax to:  910-590-8716

Mail to:  Sampson Regional Medical Center

              Attn: Health Information Management

              PO Box 260

              Clinton, NC  28329

If you have any questions regarding this process, please call 910-592-8511, ext. 8480.  The HIM department is open Monday through Friday, 8:00 a.m. - 4:00 p.m. excluding holidays.

*Please note, fees may be accessed for the printing and mailing of medical records.