Medical Record Requests

We have part­nered with Medicopy, a ful­ly HIPAA-com­pli­ant health infor­ma­tion retrieval com­pa­ny, to ful­fill the Med­ical Records Requests of our patients and to com­plete FMLA and dis­abil­i­ty forms. Medicopy adheres to all state and fed­er­al reg­u­la­tions con­cern­ing the release of med­ical information.

Request­ing Med­ical Records

A request to obtain copies of your med­ical record can be completed:

Online

• 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 tsbc@​mrocorp.​com or by fax to 1−833−606−1226.

Deliv­ery

Request­ed records will be mailed to the address spec­i­fied or sent elec­tron­i­cal­ly via encrypt­ed email, secure FTP, or requestor por­tals. Please indi­cate the pre­ferred deliv­ery method in Sec­tion 4 of the Autho­riza­tion for Release of Health Infor­ma­tion Form. Please allow up to 30 days for processing.

Fees

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.

Learn more about MediCopy’s Release of Infor­ma­tion Ser­vice. If you have any ques­tions, please con­tact MediCopy: phone: 866−587−6274 | email: request@​medicopy.​net

Request­ing Forms Completion

Please sub­mit your blank FMLA or dis­abil­i­ty paperwork:

Online

• Sub­mit your blank FMLA/​Disability forms electronically.

By Paper Form

If you pre­fer to sub­mit forms via email or fax please com­plete down­load the Intake Paper­work pdf and sub­mit it with your blank disability/​FMLA forms via email to tsbcforms@​mrocorp.​com or via fax to 833−921−0189.

Fees

MediCopy will send you an invoice to be paid before the form(s) is com­plet­ed. The cost is $30 for the first form and $15 for each addi­tion­al form turned in at the same time. 

Deliv­ery

Once pay­ment is received, MediCopy will com­plete your form(s) with­in three busi­ness days and release a copy to the des­ig­nat­ed request­ing party. 

If you have any ques­tions, please con­tact MediCopy: 

online chat: MediCopy​.net | phone: 866−587−6274