Medical Record Requests
Requesting Medical Records
We have partnered with Medicopy, a fully HIPAA compliant health information retrieval company, to fulfill the Medical Records Requests of our patients. Medicopy adheres to all state and federal regulations concerning the release of medical information and requires the request be in writing and signed either digitally or manually.
A request to obtain copies of your medical record can be completed:
- Complete the Authorization for Release of Health Information Form
By Paper Form
- If you prefer to complete a paper authorization form, please download and print the Authorization for Release of Health Information Form.
- Submit your completed paper authorization form to Medicopy by emailing firstname.lastname@example.org or by fax to 1−833−606−1226.
Please allow up to 30 days for processing.
Patients can request copies of their medical records at no cost if the delivery method is via encrypted email or to another provider outside of The South Bend Clinic. Postage fees will apply for hard copy requests, so please ensure you submit your email. If there is a fee for your request, Medicopy will provide you with an invoice summarizing the charges. Payments can be made online https://medicopy.net/, over the phone by calling 1−866−587−6274 ext 215, or by mailing a check to the address listed on the invoice. All fees are in accordance with Indiana and federal law.
Continuation of Care with other Providers
All healthcare facilities requesting medical records must fax a request to The South Bend Clinic at (574) 204‑7656. Please send the patient’s name, date of birth, and the requested information on your fax cover sheet.