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Patient Medical Record Request

Patient Medical Record Request

Faxing the form to us is the fastest and easiest way to obtain copies of your records. However, you may also request a copy of your records by sending a completed and signed printout of the medical information release authorization form to:

KMC Hospital
Release of Information Unit
4601 Medical Plaza Way
Clarksville, IN 47129

If the patient is a minor or unable to give consent, the signature of a parent, guardian or other legal representative is required.

Additional authorization may also be required for the release of specifically protected or privileged information. Certain information can take up to 30 days for processing.

Please note that a fee may be associated with a medical record request.

MEDICAL DISCLAIMER:
IF THIS IS A MEDICAL EMERGENCY, PLEASE CALL YOUR LOCAL EMERGENCY SERVICE (911) TO GET PROMPT MEDICAL ATTENTION. DO NOT RELY ON ELECTRONIC COMMUNICATIONS FOR ASSISTANCE REGARDING YOUR IMMEDIATE, URGENT MEDICAL NEEDS. THIS E-MAIL IS NOT DESIGNED TO FACILITATE MEDICAL EMERGENCIES. KMC HOSPITAL CANNOT GUARANTEE RESPONSE TIMES IF YOU CHOOSE TO USE THIS E-MAIL IN THE EVENT OF A MEDICAL EMERGENCY.

“Our providers are on a constant quest for Excellence, we are not satisfied with regression to the mean”