Frequently Asked Questions

Here are the most frequently asked questions about Good Samaritan Hospital (GSH) medical records. Selecting a question will take you directly to the answer, or scroll down the page to see answers to all the questions. If you cannot find the answer to your question here feel free to contact us. 

• How do I request a copy of my medical record? 
• When will I receive a copy of the medical record? 
• How do I get a copy of my child's medical record? 
• Can I get a copy of my living relative's medical record?
• I was born at GSH. Can I get a copy of my birth certificate from you?
• How do I get a copy of my deceased relative's medical record? 
• I was adopted and am trying to obtain medical information about my birth parent, who had been a patient at GSH.
• Is there a cost to obtain my medical records for patient care?

How do I request a copy of my medical record?

You will need to complete and submit an Authorization for Release of Medical Information/Patient Access Form. This is your authorization to copy your medical record, or parts of your record, and forward it to another person or organization. Visit the Requesting a Copy page for more information.

When will I receive a copy of the medical record?

Copies are processed within 10 working days from the date the request is received. If you come to the Medical Records/Health Information Management Services Department to pick up your copy, please bring a photo ID.

How do I get a copy of my child's medical record?

You can request a copy if your child is age 17 or younger. Complete and submit an Authorization for Release of Medical Information/Patient Access Form. Individuals age 18 and older must authorize the release of their own medical record. Visit the Requesting a Copy page for more information.

Can I get a copy of my living relative's medical record?

If your relative is unable to sign the Authorization for Release of Medical Information/Patient Access Form, his or her power of attorney can request the copy. Legal documentation must be provided by the individual who is serving as power of attorney.

I was born at GSH. Can I get a copy of my birth certificate from you?

Birth certificates for anyone born at GSH are available from the Dayton Bureau of Vital Statistics  at (937) 225-4418.

How do I get a copy of my deceased relative's medical record?

Only the representative of the estate of a deceased patient may request a copy of the medical record. You must provide copies of the death certificate and the representative of estate legal documents.

I was adopted and am trying to obtain medical information about my birth parent who had been a patient at GSH.

Without written authorization from the birth parent, information about the birth parent cannot be released.

Is there a cost to obtain my medical records for patient care?

No.  Processing fees will apply to all other requests.