Department Medical Records

At White County Memorial Hospital medical records are maintained for a period of time specified by state and federal regulations.

A patient or legal guardian of a patient may request copies of his/her medical records during the hours of 7 am - 4 pm Monday - Friday. Proper authorization for the release of medical records is required.

The Medical Records department is responsible for ensuring record completeness, accurate coding for billing purposes, transcription of reports reflecting services rendered to the patient, and maintaining the highest level of patient confidentiality related to health information.

RELEASE OF MEDICAL RECORDS

In order to release medical records a form is completed and signed by the patient or authorized representative. A form needs to be completed when a patient desires information from their medical record released to another party, i.e. an attorney, physician, insurance company. In addition, it also needs to be completed and signed when a patient wishes to receive copies of their own medical record information. It is important that the form be filled out in its entirety and signed and dated by the patient.

Download Authorization for release of Medical Health Information

Upon completion of the form, it must be presented or mailed to the Release of Information department at whichever campus the patient is requesting records from. If mailed, please include a copy of your driver's licence (or photo ID) and mail to:

If you have questions, please contact the Medical Records Department through the main hospital switchboard (574) 583-7111

BIRTH/DEATH CERTIFICATES

Birth and Death certificates may be obtained from the White County Department of Health. Additional fees may apply. You may also contact the White County Health department at (574) 583-8254.

DELEGATION OF AUTHORITY TO CONSENT TO HEALTHCARE FOR A MINOR

This form is used to give consent for emergency medical and surgical treatment of a minor in a licensed hospital, by a licensed Indiana physician in the absence of the minor's parents or legal guardian.

Download Minor Consent Form