Requesting Medical Records
Download the Records Release Form from the link on the right.
Instructions:
- Print the release form.
- Complete the form in ink.
- Fax the form to (605)-367-8247. Please include your contact information so the medical records staff can contact you if more information is needed.
Specific Instructions to complete form.
- Provide patient's Last Name, First Name and Middle Initial.
- Provide patient's Date of Birth.
- List the name of the Patient's Falls Community Health Provider if known.
- List where you would like records sent including Name, Address, and Phone Number.
- Patient (or parent/guardian) signature and date, list reationship if not patient and have a witness sign as well.
- If the release is for Mental Health, Drug/Alcohol Abuse or HIV information, initial the corresponding line and sign and date in the specific authorization portion.
- At the bottom, check the box that states what you would like to happen to the medical records.
Stop by or call Falls Community Health at 367-8793 to ask specific questions about the release.
