20151

20151 06/15/22 PAGE 1 OF 2

Form Revision History

• Proof 1 - 06/15/22

PATIENT MEDICAL RECORDS ACCESS REQUEST

Not to be used for VERBAL communication

PATIENT

INFORMATION

NAME: DATE OF BIRTH: Last 4 digits of SS#:

Address: Day Phone: City: State: Zip:

Clinic/Hospital/

Healthcare

Provider-

(Who has the

information you want

released? Please list the

specic Hospital and/

or clinic)

LOCATION of service provided. Please check all that apply,

COMMUNITY HOSPITAL:

 Anderson

 East

 Heart & Vascular (a facility under CHE)

 North

 South

 Westview (a facility under CHE)

 Howard Regional Health

 Howard Specialty Hospital

COMMUNITY SURGERY CENTER:

 East

 Hamilton

 Howard

 North

 Northwest

 Plus

 South

 Digestive Centers Anderson

 Endoscopy Center Indianapolis

OTHER:

 Cancer Centers

 Community Fairbanks Behavioral Health

 Inpatient  Outpatient

 Community Fairbanks Behavioral Health Howard

 Home Health

 Imaging Centers

 Medchecks

 Physical Therapy Oces

 Physician Network

Physician Practice Name

Receiving Party

(Where and to

whom do you want

the records sent?)

 Me  Other

NAME:

Address: City: State: Zip:

Day Phone: Fax Number

Email Address:

Information to be

Released

(What do you

want? Check the

appropriate box(es).)

Disclosure will include (check all that apply):

 Consultation Report  Discharge Summary/Notes  Emergency Record(s)  History and Physical Report  Forensic Photos  Entire Record

 Immunization/Allergy Records  Laboratory/Pathology Report  Medication Report  Oce Visits  Operative Report  Communicable Diseases

 Progress Notes/Clinic Notes  Films/Images  Therapy Records  X-ray/Radiology Report  Forensic Consult  Billing Records

 Substance Abuse Records  Mental Health Records  BH Treatment Plan  BH Diagnosis  BH Evaluation/Assessment

 Other records specify record type(s)

Date(s) of Service _________________________ Illness or injury ___________________________________________________

Release

Instructions

(How and When

do you want the

information?)

Date information is needed:_____________________ (NOTE: PLEASE ALLOW 30 DAYS FOR PROCESSING)

Release Method/Format requested: (check one)

 MyChart  Paper  CD/DVD  Fax

 Secured e-mail

 Unsecured e-mail (E-mail is not a secure form of communication. See page 2 for details)

 I have read the warning on page 2 and wish to receive my records from Community Health Network via

unsecured e-mail.

Signature for Unsecured Email

 Other*

*Requests for other methods of delivery will be reviewed on a case by case basis

Patient/Legal Guardian Signature Date/Time Authority to act on behalf of patient (attach document)

*20151*

PATIENT IDENTIFICATION

PATIENT MEDICAL RECORDS ACCESS REQUEST

20151 06/15/22 PAGE 2 OF 2

Form Revision History

• Proof 1 - 06/15/22

DIRECTIONS FOR COMPLETION OF THIS FORM

Patient Information: Complete the entire section which identies clearly and legibly all of the demographic information specic to the patient

(individual who information is being requested for).

Clinic/Healthcare Provider: Identify which Community Health Network facility you are seeking information from (or to be sent to). Please be

specic 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 specic facility, records may be provided to ALL Community Health Network facilities where you

have received care. Please see www.eCommunity.com for a listing of Community Health Network locations and names.

Receiving Party: Identify 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 Requested: This section gives us the instructions for what information you want released.

Release Instructions: This tells us how you would like your information delivered. We can print the documents, mail, secure email, or create a CD.

If we are unable to provide in the format desired we will contact you to make other arrangements.

Please read the warnings below and sign on the front of the page if you agree to unsecure e-mail.

• 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.

Contact Information

Community Health Network

Health Information Management-ROI

1500 North Ritter Avenue

Indianapolis, IN 46219

Phone: 317.355.5802

Fax: 317.351.7728

For any questions/follow-up regarding your request please e-mail releaseonformation@eCommunity.com

To submit a request for records please e-mail to ROIRequests@eCommunity.com

Patient Name: _________________________________________________________ Date of Birth: _______________