PATIENT MEDICAL RECORDS

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• Patient's full name and date of birth (list any other names the patient may have had)

• Telephone number

• Medical Record Number (if available)

• Specific information being requested (e.g., type of report/information and dates of service, etc.)

• Purpose for which the information is being disclosed

• To whom the information is to be sent (name, address, and phone)

• Authorizations are good for one year from signature date unless otherwise specified

• The patient's signature or a patient's legal representative's signature. Authorizations signed by a representative must contain a copy of the guardianship papers or power of attorney

• Date of the signature

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To request your medical records, you may complete and mail the Request to Inspect or Copy Health Information, or send a written request complete with the following information:

All written requests should be mailed to:

Clara Barton Hospital

Health Information Management (HIM)
250 West 9th Street
Hoisington, KS 67544

Phone: (620) 653-5092
Fax: (620) 653-2671

Email: HIM@cbhks.com

Your request will be processed within 30 days, and will be sent to you, or

you may pick up your medical records in our office between 8:00am and 4:00pm.

Processing Fee: We will notify you by phone in advance if there will be a charge for your records.