Request a Copy
You can request a copy of your Good Samaritan Hospital (GSH) medical record to be sent to you or a designated recipient. A processing fee may be required.
Written Authorization Required
The Authorization for Release of Medical Information/Patient Access Form is your authorization to copy your GSH medical record or parts of your record, and forward it to another person or organization. Your original signature is checked against our records to validate the authenticity of your request.
You can get this form one of three ways:
- Download it. To open the form you’ll need Adobe® Acrobat Reader®, which you can download for free
.
- Call the Medical Records/Health Information Management Services Department to request that the form be mailed to you: (937) 734-8316.
- Stop by the Medical Records/Health Information Management Services Department during regular business hours, 8:00 a.m. to 4:00 p.m. Monday – Friday. (You will need to show a valid form of personal identification.)
Submitting an Authorization
Submit a signed copy of the authorization form by mail, fax, or in person.
Mail:
|
Good Samaritan Hospital
ATTN: Health Information Management Services
2222 Philadelphia Drive
Dayton, OH 45406 |
| Fax: |
(937) 734-8214 |
| In person: |
The Medical Records/Health Information Management Services Department is located on the ground floor of the North Building.
Hours are from 8:00 a.m. to 4:00 p.m. Monday – Friday.
|
Please allow up to 7 to 10 working days for your request to be processed. If you come to the Medical Records/Health Information Management Services Department to pick up your copy, please bring a photo ID.
Who Can Request a Copy?
The following people are authorized to sign for release of medical records:
- Patient (not the spouse)
- Parent (if the patient is younger than age 18)
- Legal guardian (proof of guardianship document must be provided)
- Power of attorney if the patient is unable to sign (legal documentation must be provided)
- Representative of the estate for a deceased patient (legal documentation must be provided, including a copy of the death certificate)
Processing Fees
HealthPort is a contracted copy service at GSH in Medical Records/Health Information Management Services. The phone number is (937) 734-8316. HealthPort's standard fees for copying medical records are:
| Patient Access Fees from a chart or electronic recored |
|
| 1 to 10 pages |
$1.15 per page |
| 11 to 50 pages |
$.59 per page |
| 51 pages or more |
$.24 per page |
| Copies from Microfilm |
$1.87 per page |
Note: Prices do not include tax.
There is no charge if records are sent directly to your physician.
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