Requesting Medical Records

Requesting Medical Records

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

Instructions:

  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.