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Request Medical Records

To request a copy of medical records for care received at South Bend Clinic, please complete a Patient Request for Access (Form 3000A).  Once you have signed the request, please return it to any of the South Bend Clinic locations.  You may also send it to us by fax or mail using the information provided below. If you are enrolled in My Clinic Patient Portal, you may send us a message with any questions you may have. To access My Clinic Patient Portal, please click this link.  

Attn: Release of Information (Health Information Management Department)
211 North Eddy Street
South Bend, IN 46617

Fax: 574.204.7656
Phone: 574.237.9307

The Patient Request for Access Form

The Patient Request for Access form is available in the Downloads box at the bottom of the page, along with instructions for completing the form.  South Bend Clinic retains patient records for 10 years.  

Medical Record Process

This process is in compliance with Federal HIPAA guidelines. Please allow up to 30 business days for your records to be processed and mailed to the specified address.

Continuation of Care with other Providers

All Healthcare facilities requesting medical records must fax a request to South Bend Clinic at (574) 204-7656. Please send the patient name, date of birth and information you are requesting on your fax coversheet and we will fax records back to you. All large volumes of documentation will be mailed and not faxed.

Who is authorized to sign for release of my medical records?

  • You, the patient, if not a minor.
  • Your health care representative or health care Power of Attorney if you are unable to sign. Legal documents must be provided.
  • If you are under 18 years of age, your parent/parents may sign for you.
  • Legal guardian if appropriate. Documentation must be provided.
  • For deceased patients, the Executor of the Estate is the first person who can request copies of records. Death certificates and estate documents must be presented.

Patient Request for Access form



Form Instructions


 * The South Bend Clinic, LLP and SurgiCenter complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

The South Bend Clinic Main Campus Health Information Management Department will process requests Monday through Friday through our HIM Customer Service Window from 8:00a.m. to 5:00 p.m.