Reid Health HIM | Patient Medical Record Release Form

Patient Medical Record Release Form

Patients or authorized representatives of the patient may fill out this form to submit an online request for the release of medical records from Reid Health. If you have questions or need further assistance, please direct questions to our Health Information Management department at (765) 983-3174 or HIM-ROI@reidhealth.org.
Patient Contact Information
Relationship to Patient:
Your Contact Information*

Your first nameYour middle name/middle initialYour last name
Your address*

Street Address

Street Address Line 2

CityState

Zip Code
Best Contact Number to Reach You*
Please enter a valid phone number.
Patient's Name*

First NameMiddle Name/InitialLast Name
Last 4 digital of patient's SSN*
Patient's Date of Birth*

MonthDayYear
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Best Contact Number for Patient*
Please enter a valid phone number.
Purpose of disclosure (please select all that apply)*

Transfer of carePersonalInsurance/billingLegalEmploymentCompliance with courtCollaboration with schoolConfirmation of referralOther
Purpose of disclosure (please select all that apply)*

Insurance/billingLegalCompliance with courtOther
Purpose of disclosure (please select all that apply)*

Transfer of careContinuum of careOther
Patient Health Information

Hospital, practice, department, or service line that has the patient's medical records. Please be careful to select all relevant facilities.
Reid Health - Richmond or ConnersvilleReid Health Geriatrics & Transitional MedicineReid Internal MedicineBethel Cardiology of GreenvilleReid Health Perioperative ClinicReid Medical AssociatesOutpatient Behavioral Health - ConnersvilleReid Health Primary & Specialty Care - BrookvilleReid Neurology AssociatesOutpatient Behavioral Health - RichmondReid Health Primary & Specialty Care - Cambridge CityReid OB/GYNReid AllergyReid Health Primary & Specialty Care - ConnersvilleReid Pediatric & Internal MedicineReid AudiologyReid Health Primary & Specialty Care - HagerstownReid Plastic & Reconstructive SurgeryReid Cardiothoracic SurgeonsReid Health Primary & Specialty Care - New CastleReid Pulmonary CareReid DermatologyReid Health Primary & Specialty Care - WinchesterReid Ready Care ClinicReid Eaton Family & Specialty CareReid Health Oncology AssociatesReid Vascular SurgeryReid EndocrinologyReid Health RadiologyReid Wound Healing CenterReid ENTReid Health Residency ClinicRichmond Cardiology AssociatesReid Family HealthReid Health Urgent Care - ConnersvilleSleep Disorder CenterReid General SurgeonsReid Health Urgent Care - EatonState Line Family MedicineReid Health Care PavilionReid Health Urgent Care - RichmondUrological CareReid Health Comprehensive Bone & Joint CenterReid Infectious DiseaseWhitewater Valley Primary CareReid Health GastroenterologyOther
Where should the Medical Records be sent?

Please tell us where these medical records should be sent. If you are not selecting to have the records sent to yourself, please also supply the recipient's contact information. Please allow 30 days from the receipt of the request to have records processed and sent to the recipient.
Who is receiving these records?*
Name of person or organization receiving records

Individual's first name or organization's nameLast Name or disregard if sending to organization
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Daytime Phone
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Specific Information to be Disclosed

Please select all relevant options.
Dates of Service*

All records on fileSpecific time frame
Start Date of Service

MonthDayYear
Date
End Date of Service

MonthDayYear
Date
Information to include:*

Entire recordDischarge summaryHistory and physicalConsultation reportOperative reportImmunization/health recordsPsychiatric evaluation/treatmentAssessmentSchool eval reports, grades, discipline recordsPathology reportX-ray resultLaboratory result/drug screeningDiagnostic resultPsychological test resultSubstance use disorder diagnosisDiagnostic impressionFunctional behavioral assessments, 504 plans, treatment plans, disability determinationEmergency room reportMedicationsEmployer requested treatment/testDischarge/Aftercare planClassroom behavior/assessmentSubstance use disorder treatmentTreatment summaryBilling/claim informationOther
Instructions for Health Information Release

Please let us know when you need to receive this information and in what format you'd like to have it delivered.
Date that you'd like to have information:
NOTE: Please allow 30 days for this request
In what way would you like to receive the record?*

MyChartMail (USPS)CD/DVDFaxEmail (secured)Email (unsecured)Other
In what way would you like to receive the record?*

MailCD/DVDFaxEmail (secured)Other
Fax Number
Please enter a valid fax number where records can be sent.
Email
example@example.com
There are risks to sending personal health information through unsecured email channels. By selecting this option, I am consenting to the understanding that:
- Anyone who comes in contact with this information has the ability to read it.
- E-mail may be read when it is stored on a unsecured server.
- E-mail may not be fully disposed of or destroyed even after it has been archieved/stored on an email server.
- Personal medical records may contain extensive data that has monetary value on the "dark web." This means that I know that I am at risk for medical identity theft.
Authorization to Release/Obtain Medical Information
I authorize the release of the above information relating to my general medical treatment and/or any treatment relating to alcohol/drug abuse, mental illness, psychiatric treatment, developmental disabilities, HIV/AIDS, Gonorrhea, Hepatitis (viral), Syphilis, Chancroid Chlamydia infections, Lymphogranuloma Venerum or Genetic Testing. I further authorize the information to be faxed or electronically sent.

I understand this authorization may be revoked at any time, providing the information has not already been disclosed. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Health Information Management Department at Reid Health. I also understand that once the above information has been disclosed per my instruction, the information may no longer be protected by the confidentiality laws.

I understand that my records are protected under State and Federal confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in regulations.

This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to a publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except provided at 2.12 (c) (5) and 2.65.

I hereby state that I have read and fully understand the above statements.

Please sign below or upload signed patient authorization form.
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Patient Medical Record Release Form

Patient Contact Information

Patient Health Information

Where should the Medical Records be sent?

Specific Information to be Disclosed

Instructions for Health Information Release

Authorization to Release/Obtain Medical Information