Release of Information Form

Reid Health takes patient privacy very seriously.

Please find below a printable release of information form as well as instructions for how to complete the form appropriately.  It is necessary to have a release of information form completed and on file within the Health Information Management Department (Medical Records) prior to records being released.

Please provide specifics regarding what is to be released by checking the appropriate box(es) i.e. Discharge Summary, Laboratory Report, etc.  If the appropriate item is not listed, please write in the specific information that you are requesting so that your authorization can be completed correctly.  You must also provide the dates of service for which this request is being made.  You may not request future dates of service.

The completed form must be presented to the Health Information Management Department in order for the release of information to take place.  Please bring personal identification to verify that you are legally entitled to the release of the medical information.

The Health Information Management Department (Medical Records) is located in the 600 Building across from Elder Beerman in downtown Richmond., and the regular business hours are Monday through Friday 8 a.m. until 4:30 p.m.  If you have any questions, please contact us at (765) 983-3371.

These documents are in PDF format and will require Adobe Reader to open.

Release of Information Instructions – Instructions on completing the release of information authorization form.  Please read this document before completing the form.

Release of Information Form – Printable release of information authorization form.