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 and first name
• Date of birth
• phone number
• Social Security number
• Provider/facility name and phone number for who is releasing the information
• Provider/facility name and phone number for where the information is to be sent
• Information to be disclosed
• Purpose of disclosure
• Expiration date (will be filled in when signed)
• Signature and date of patient/representative. (Must be signed in person)

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.