Medical Records - Release of Information

A patient, or his/her legal representative, may inspect and/or obtain a copy, or have copies of medical records sent to another facility. There may be a charge for this service.

Kosciusko Community Hospital requires a completed and signed written request or authorization form for release of protected health information before releasing any documents to anyone, including the patient.

Obtaining Copies of Your Medical Records Release of Information (ROI)
Records can be released to anyone that the patient authorizes (in writing along with photo ID). A valid authorization MUST be fully completed, dated and signed or the request will be returned.

Forms completed by Power of Attorney (POA) require a copy of POA paperwork.

Medical records may be request by a competent patient if the patient is 18 years of age or has been emancipated.

Medical records of a deceased patient may be requested by the personal representative of the patient's estate If the deceased does not have a personal representative, his or her spouse may make a request. If there is no spouse, a child of the deceased patient (or the parent, guardian or custodian of the child if the child is incompetent) may make a request.

If the patient did not die within Kosciusko Community Hospital, verify death by providing a copy of the death certificate. All requests will be reviewed to determine the identity of the requestor.

To Request a Copy of Medical Records Pertaining to You

  • Print and complete the PHI-Authorization for Use and Disclosure form.
  • The form must be completed, dated and signed.
  • We ask that you specify what components of the medical records you wish to obtain. Often, the discharge summary, operative report and history and physical contain relevant information to suit your needs.
  • If you have any questions regarding release of health information, please call (260) 435-7271.

To submit your request once your form is completed:

Please bring form to:
Kosciusko Hospital Lobby-Release of Information Office-ask greeters for directions
2101 E Dubois Dr
Warsaw IN 46580

Mail form to:
ROI Office
2101 E Dubois Dr
Warsaw IN 46580

Fax form to:
574 372-7620 primary
574-372-5813 secondary

Release of Information Charges

  • There may be a fee for this service.
  • There will be no charge if requested materials are going to another healthcare facility to maintain continuity of care.

Additional Information
Please allow up to 14 calendar days for your request to be processed. Records will be sent through U.S. Mail unless indicated to pick-up. You may be contacted by the Release of Information Office when your records are ready. A photo ID is required.