How to Request a Copy of Your Medical Records
Please complete a Patient Request for Access (Form 3000A, below) and return it to any of the South Bend Clinic locations.
You may also send the form by fax or mail using the information provided below.
Attn: Release of Information (Health Information Management Department)
211 North Eddy Street
South Bend, IN 46617
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.
Please note that South Bend Clinic retains its patient records for 10 years.
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.
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 cover sheet.
We fax the records to you unless there is a large volume of documentation. Those files are mailed.