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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.

Printable release of information authorization form: Consent – Authorization to Release or Obtain Medical Information 

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Discrimination is Against the Law. We comply with applicable Federal civil rights laws and Indiana laws. We do not discriminate against, exclude or treat people differently because of race, color, national origin, age, disability, sex, sexual orientation or gender identity. Please see our Patients’ Bill of Rights.

Reid Health
1100 Reid Parkway
Richmond, IN 47374
Our form 990, annual reports & financial statements are available upon request.