Requesting Medical Records
Download the Records Release Form from the link on the right.
Instructions:
- Print the release form.
- Complete the form in ink.
- 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.
Complete 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 reationship if not patient and have a witness sign as well.
Stop by or call Falls Community Health at 367-8793 to ask specific questions about the release.
