Requesting Medical Records

check boxesTo request a copy of medical records for care received at Eskenazi Health (both the Sidney & Lois Eskenazi Hospital and the Eskenazi Health Center sites), please complete an Authorization for Release of Confidential Information and return it in person, via mail or via fax to:

Eskenazi Health
Attn: Release of Information (Eskenazi Health Information Management)
720 Eskenazi Ave.
Indianapolis, IN 46202
Fax: 317.880.0469
Phone: 317.880.3454

An Authorization for Release of Confidential Information can also be returned to your nearest Eskenazi Health Center site.

 

Authorization for Release of Confidential Information Form

The Authorization for Release of Information form in English and Spanish is available in the Downloads box at the bottom of the page, as well as instructions for completing the form.

Medical Record Process

This process is in compliance with Federal HIPAA guidelines. Please allow up to 30 business days for your records to be processed and mailed to the specified address.

Eskenazi Health contracts with HealthPort for this service. The following fees apply (indicated below) to process your request and you will receive an invoice along with your records.

Who is authorized to sign for release of my medical records?

  • You, the patient if not a minor.
  • Your health care representative or health care Power of Attorney if you are unable to sign. Legal documents must be provided.
  • If you are under 18 years of age, your parent/parents may sign for you.
  • Legal guardian if appropriate. Documentation must be provided.
  • For deceased patients, the Executor of the Estate is the first person who can request copies of records. Death certificates and estate documents must be presented.
Authorization for Release of Confidential Information
Form English Spanish
Form Instructions English Spanish

Fees

 

  • Pages 1 thru 10 – each page $1.00
  • Pages 11 thru 50 – each page $.50
  • Pages 51 plus - $.25
  • Plus postage and tax

Eskenazi Health Information Management will process requests Monday through Friday from 7:30 a.m. to 4 p.m.