Request Medical Records

Stop by or call Falls Community Health at 605-367-8793 to ask specific questions about the release.

By Fax

Step 1.Print the release form.

Download and print the Medical Records Release Form.

Step 2.Complete the form in ink.

Please complete the entire form. Required fields include:

  • Patient's Last Name, First Name and Middle Initial.
  • Patient's Date of Birth.
  • Where you would like records sent including Name, Address, and Phone Number.
  • Information to be disclosed.
  • Purpose of disclosure. 
  • Patient (or parent/guardian) signature and date, list relationship if not patient and have a witness sign as well.

Step 3.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.