Authorization for Use & Disclosure of Protected Health Information

Pricing and Information

Medical record copies delivered directly to the patient for personal use will cost $6.50.

Medical record copies delivered directly to a healthcare provider will be free of charge.

Medical record copies for all other purposes will be charged at applicable rates with payment due in advance and payable to Resolve ROI.

Requests for X-ray, MRI or images on disc are $20 per disc (+ delivery cost).

You will receive an invoice for any charges associated with your request.

Printable Form

If you prefer to download and print a paper contract, click here.

Support and Contact Information

For any questions related to our process please contact ResolveROI at (844) 887-8109 or