Patient Medical Record Request Form

Patients and/or authorized patient representatives may use this form to submit a medical records request online.

*To request records for Community Fairbanks Recovery Center, click here. 

For questions, please call the Community Health Network HIM Department at 317-355-5802 or visit our website.

Patient Information

Complete the entire section of demographic information specific to the patient (individual whose information is being requested).

Clinic/Hospital/Healthcare Provider

Who has the information you want released? Please list the specific hospitals and/or clinics.

Identify which Community Health Network facility you are seeking information from (or to be sent to). Please be specific in your request. For example, when choosing Community Physician Network please add either the name of the provider or the practice name you are requesting. If you do not identify a specific facility, records may be provided for ALL Community Health Network facilities where you have received care.
Location (check all that apply):

Receiving Party

Where and to whom do you want the records sent? If not for yourself, please include the full name/business, address, phone and contact information with the name of the individual who is to receive the information. Please allow 30 days for all requests to be processed and sent to the recipient.

Information to be Released

What do you want sent or released? Check the appropriate box(es).
Note: Birth and death records may be requested through the Indiana Department of Health’s Vital Records office.
Disclosure will include (check all that apply):
Indicate first day of service period for which you are requesting records. If the health service was on a single day, enter the same date in Start and End Date fields.
Indicate last day of service period for which you are requesting records. If the health service was on a single day, enter the same date in Start and End Date fields.

Release Instructions

How and when do you want the information? If we are unable to provide in the format desired we will contact you to make other arrangements.
NOTE: PLEASE ALLOW 30 DAYS FOR PROCESSING
Release method/format requested (check ONE):
*Requests for other methods of delivery will be reviewed on a case-by-case basis.
  • Any e-mail (including those claiming to be private) is often compared to a postcard in that anyone who comes in contact with it can read it.
  • E-mail may be read when it is stored on internet service provider servers.
  • E-mail is hard to destroy because it is archived/stored on e-mail servers.
  • Medical records contain extensive data with monetary value and can be bought and sold on “the dark web” for medical identity theft and other illicit purposes.

Documentation

Documentation may be required depending on relationship to patient.
Please Note: Documentation is required for legal guardianship requests. If you select this, you will see an option to upload documentation below to submit with your request. Otherwise, no additional documentation is required.
Please Note: Court-issued documentation of the selected relationship to patient is required for all "other adult" medical record requests. Please upload appropriate documents below to submit with your request.

If patient is identified as "self" no additional documentation is needed for the medical records request.

Healthcare Power of Attorney documentation must be submitted.

Appointed healthcare representative documentation must be submitted.

Court-issued guardianship documentation must be submitted.

Submit documentation of appointment.

Please provide a copy of the death certificate.

One file only.
10 MB limit.
Allowed types: pdf, doc, docx, jpg.

Signature