Susan Stanley, RHIT
Director of HealthInformation Management
Phone
Fax
PATIENT MEDICAL RECORDS
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Patient's full name and date of birth (list any other names the patient may have had)
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Telephone number
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Medical Record Number (if available)
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Specific information being requested (e.g., type of report/information and dates of service, etc.)
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Purpose for which the information is being disclosed
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To whom the information is to be sent (name, address, and phone)
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Authorizations are good for one year from signature date unless otherwise specified
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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
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Date of the signature
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 7:00am and 5:00 pm.
Processing Fee: We will notify you by phone in advance if there will be a charge for your records.
