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The Health Information Management Department is to here to assist all patients in obtaining their healthcare related information. To ensure your privacy, McKenzie Health System will only release medical records to the person receiving treatment or their legal representative in accordance with federal laws.
How to Request Medical Records
Medical records may be requested from the Health Information Management Department.
To request medical records, complete and submit the following:
- MHS Authorization Form: Release of Protected Health Information. (Download Form)
- Complete all areas. Be sure to specify the dates of service and types of information needed (i.e.: ER report from specific date of service).
- Copy of Driver’s License or Photo ID
- Guardianship or Durable Power of Attorney Papers (if applicable)
A valid authorization MUST contain the following information or the request will be returned:
- Patient’s full name and date of birth (list any other names the patient may have had)
- Specific information be requested (i.e.: type of report/ information and dates of service, etc.)
- Purpose for which the information may be disclosed
- To who the information is to be sent (name and address)
- Specify authorization’s expiration date if desired (see bottom of the ROI form)
- The patient’s signature or a patient’s legal representative’s signature. Authorizations signed by a representative must contain a copy of the guardianship or power of attorney papers.
- Date of the signature.
Send Completed Release of Protected Health Information form to the Health Information management Department. If records are not to be sent to another healthcare provider please indicate the method in which you prefer to receive the records:
- Schedule an in-person pick up,
- fax or
Completed form, photo ID and/or Personal Representative paperwork can be returned by mail, fax, email or in person.
McKenzie Health System
Attn: HIM Dept
120 Delaware Street
Sandusky, MI 48471
Office hours: Monday through Friday, 7:00 a.m. to 4:30 p.m.