Requesting Medical Records

Requesting Medical Records

Download the Records Release Form from the link on the right.


  1. Print the release form.
  2. Complete the form in ink.
  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.

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.