Medical Record Request Release of Information Form

Reid Health takes patient privacy very seriously.

Below is a printable Release of Information Form as well as instructions for how to fill it out appropriately. It's necessary to have this form completed and on file with Reid's Health Information Management Department (Medical Records) before records can be released.

Please provide specifics about what is to be released by checking the appropriate box or boxes (for example, discharge summary, laboratory report, etc.). If the appropriate item isn't listed on the form, please write in the specific information you're requesting. 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 for the information to be released. Please bring personal identification to verify you're legally entitled to the release of the medical information.

Medical Records Request Patient Request

Medical records can be requested by a patient or a parent/legal guardian if a patient is under 18 years old. There are different options for requesting these records, all designed to make the process easy and convenient.


After-visit summaries and medical records can be requested from the patient's MyChart patient portal.

For those with existing MyChart accounts, you can access patient records by selecting the menu option that appears as an icon with 3 stacked horizontal bars.

If you or the patient does not have a MyChart account, please access this page to set one up. If you've not yet received an activation code, you can request a code by visiting this page.

Medical records will be delivered directly to your MyChart account.

Log in to MyChart

Online Request Form

Outside of MyChart, patients can request their medical records by submitting an online request.

Access Online Form

Mail or Fax

Medical records can be requested via mail or fax by downloading the Consent -- Authorization to Release or Obtain Medical Information Form. Before completing the form, please be sure to read the Release of Information Instructions. If all information isn't accurately provided on the form, HIM cannot fulfill the request.

The form can be mailed or faxed to:

Reid Health

ATTN: Health Information Management (HIM)

1100 Reid Parkway

Richmond, IN 47374

FAX: (765) 983-3240

Release of Information Instructions

Download Consent Form

Medical Records Request Healthcare Provider Request

Healthcare providers can fax their requests to (765) 983-3240.

All faxed requests need to be sent with patient identifiers, contact information, and a description of the information needed.

HIM office hours are 8 a.m. to 4:30 p.m. Monday through Friday.

Please view instructions for patient medical forms release here. If additional help is needed, please call (765) 983-3174.

There are two options for requesting medical records. Healthcare providers can either fax a signed Patient Authorization Form or they can submit via our Online Medical Requests Request.

Patient Authorization Form

Online Medial Records Request

Medical Records Request Third-Party Request

Requests made by attorneys or third-party services can be submitted online, by fax, or mail.

Online Request Form


Reid Health Network

ATTN: Health Information Management (HIM)

1100 Reid Parkway

Richmond, IN 47374

Fax: (765) 983-3240

Instructions for Medical Forms Release

Patient Authorization Form

Questions? We're here to help.

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