Request Medical Records

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.