Medical Records Request

You can request release of your medical records or a copy of your medical records by filling out the attached form and faxing into SinaiClinic Hospital Health Information Services at +20693666854.  You can also mail the form to :

SinaiClinic Hospital



If you have any questions, please feel free to contact the Correspondence Coordinator at the Health Information Services Department, Saturday - thrusday, between 12:00 a.m. -07:00 p.m. at +20693666851 .  To check the status of a request,  request to be transferred to MRO.

Medical Records Release Form(must have adobe acrobat to download).


When requesting information, please note the following requirements:

  1. Use of the SinaiClinic Hospital form is not required but does make the process quicker and easier since the required elements are on the form.  .
  2. If the patient is 18 years or older, they must sign the release.  If the patient is under 18 years old, the patient or guardian must sign the release.  (There are some exceptions to this.)
  3. If releasing records to yourself or to an attorney, release must be notarized.
  4. If patient is deceased, the notarized signature must be signed by the personal representative as described by law.  We will need proof of legal documents.
  5. If records are to be released to yourself, we do have 10 days to process your request upon receipt of request.
  6. Please give as much information as possible when requesting records, i.e., print name, date of birth, name of doctor, approximate date of visit and type of treatment rendered.

Instructions for completing the Medical Records Release form from SinaiClinic Hospital:

  • Complete the top portion of the authorization with the patient's name, address, date of birth, and telephone number.
  • Complete necessary information regarding who will be receiving the information:  name, complete address and/or fax number.
  • Specify which items are to be released. Specify the Dates (timeframe) for the requested information.
  • Purpose for disclosure needs to relate to the receiver of the information.
  • Complete the date for expiration of the consent.  Consents should be stated to expire within one year of the date requested unless the patient consents and documents a different date.  Patient must initial.
  • Patient must initial revocation section.
  • Patient must initial drug, alcohol, and psychiatric exclusion.  If patient does NOT wish the sensitive information to be released, also check the exclusion.
  • Signature of patient or legal guardian.
  • Date of signature.
  • If the person signing the consent is not the patient, document the relationship.
  • Notary Public or SinaiClinic Hospital witness is required for releases non-medical in purpose.
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