We strive to make it as easy as possible for you to obtain a copy of your medical record. Please note that in compliance with state and federal laws, all requests must be submitted in writing, form be completely filled out and signed with a witness signature.
How to request your medical record
On the form you will indicate which records to be released (Lab, Radiology, Emergency Room, Respiratory, Walk-In Clinic, etc.) and how we should release the records. Please allow up to 14 days for the request to be processed.
The first copy of a record is free, but additional copies thereafter has a charge of $1.00 per page. However, if records are being sent to another physician, the fee will be waived.
Submit the Form
The completed and signed form may be mailed, faxed, or delivered to:
Attn: Health Information Management Services Department
111 E Main St
Salem, KY 42078