We know that sometimes you need to have forms (FMLA, accommodations, disability, etc.) completed by your provider and we are happy to complete your forms and upload them into your patient portal. Once we receive your request, we will make sure we have everything we need to complete your forms and upload your completed document (s) or records into the patient portal. You will be notified that your document has been uploaded and you can download the document and ensure proper delivery. Please allow 5 business days for this service.
We can also fax or mail your records. However, HIPAA requires us to keep a detailed log anytime we send Patient Health Information (PHI) outside of MBC. So, this option requires an extra step as we need to have you fill out a Release of Information to authorize us to send your documents outside of your MBC patient portal. Please complete this form and attach the document. If we have any questions, we will contact you.
Please allow 5 business days for these services. Unfortunately, we can not bill insurance for the completion of forms, so we have an additional fee to compensate the provider for their time to complete the form and we pass on any additional fees associated with the transmission of the data.
|Patient Request||Fee Schedule|
|Base Fee for Completion of Paperwork Request||Uploaded into Patient Portal||Faxed||Mailed|
|Request for Records to be sent to another provider||$15.00 + cost to Fax or Mail document, if applicable||No additional cost||$0.05 per page||$0.35/page for recycled paper copy + shipping|
|Summary of Treatment||$15.00 + cost to Fax or Mail document, if applicable||No additional cost||$0.05 per page||$0.35/page for recycled paper copy + shipping|
|Completion of Forms and Reports (FMLA, Accommodation Forms, Disability, etc.) Must have attended 6 sessions with an LCPC/LCSW/Psy.D. or 3 sessions with a Nurse Practioner and account must be in good standing before documents can be completed.||$35.00 + cost to Fax or Mail document, if applicable||No additional cost||$0.05 per page||$0.05 per page|
To submit a request for our staff to complete a document, write a letter, or complete a request related to your medical records, please complete this Form.
Additionally, please feel free to contact our Client Relations Team at 312-279-9981 for more information.