If you are interested in obtaining a copy of your medical record(s), please print and complete the Authorization For Release of Protected Health Information (PDF - 28 KB).
ROI Fee Schedule (PDF - 52 KB)
Upon completion, you may fax, mail, or personally deliver your Authorization to the Health Information Management (HIM) Department at Twin Cities Hospital.
In order to verify your identification and validate your authorization, we require that you include a legible copy of a valid photo I.D. (e.g., driver's license, military I.D. or state I.D.), and a telephone number. Per Florida statute, there may be a charge for providing the copy. (if possible, state actual fee)
Please allow 48 hours for us to process your request.
What is an Advance Directive?
It is a written or oral statement about how you want medical decisions made should you be unable to make them yourself and/or it can express your wish to make an anatomical donation after death. Some people make advance directives when they are diagnosed with a life-threatening illness. Others put their wishes into writing while they are healthy, often as part of their estate planning. To obtain forms to designate a Power of Attorney or Healthcare Surrogate, or to create a Living Will, please access the PDF documents below.
- Advanced Directives Designation of Healthcare Surragate
- Durable Power of Attorney
- Advanced Directive Living Will
Twin Cities Hospital
Health Information Management (HIM) Department
2190 Highway 85 N, Niceville, FL 32578
Tel: (850) 729-9340
Fax: (850) 729-9342
Monday - Friday: 8:30 am - 4:30 pm
For further information or assistance with the Authorization Form, please call (850) 729-9340.