Who may request a release of your information
- If the patient is a competent adult, only the patient may authorize release of records.
- If the patient is under 18 years of age, the parent or guardian should sign under usual circumstances. A document of proof is required for Legal Custodian. Minor can give authorization when the minor has special legal status as an emancipated minor, i.e., married or previously married, on active duty with the armed forces, ore emancipated by court order, or a self-sufficient minor. b. Consent for treatment of the specific condition is governed by special laws giving the minor the right of consent, i.e, prevention or care of pregnancy, substance abuse and certain communicable diseases.
- Patient adjudged incompetent: Legal guardian with document of proof required (temporary guardian if appointed by the court.)
- Durable Power of Attorney for Health Care designee may give authorization.
- Your request may take up to 30 days to complete.
Instructions
- Fill in complete patient name, date of birth and social security number. This allows us to locate the proper patient and protect privacy.
- PHI-Release To: If copies are for personal use and you are picking them up, please document your complete name and address. If the records are being picked up by another person or mailed, please provide the complete name and address of that person, clinic, hospital etc. you would like us to release the copies to.
- Purpose of Disclosure: We are required to document why we release information. Why do you need this information copied or sent? (ie: personal copy, continuation of care by a physician, insurance claim, legal issues, etc.)
- Expiration Date: Any date not to exceed 12 months from the date of the request may be used to indicate the active state of this authorization. If no date is provided, the authorization will only be valid for 90 days from the date it was signed.
- Documents Requested: Check the box corresponding with the documentation you are requesting. Type of document requested: Mark all documents you would like to receive. An abstract version may be provided which would include all diagnostic (lab, x-ray, EKG, etc.) and typed physician reports. This is generally what most other Health care providers like to have. We prefer to have the admission or discharge dates, however the approximate month and correct year will be accepted if the exact day/date is not known. If you are requesting records for more than one admission or visit, please include each date range you are requesting.
- Patient Signature: Patient is required to sign and date the form. If the patient is unable to sign or if request is being made by an authorized representative of the patient (parent of a minor, person named on Power of Attorney, executor of estate, etc.), sign and date the form. Provide printed name, address, etc. Proof of authorization will be required before releasing information.
- Disclosure Format: When picking up copies in person, a photo ID will be required as well as a copy of any legal papers (Power of Attorney, Executor of Estate, proof of custody, etc.) verifying legal right to request such information. There will be a charge for copies of medical records requested for personal use.
- Witness Signature: A witness may sign and date the form in the event that the patient can only make an X or has given verbal permission.
Submit Medical Records Request Online
A Medical Records Request can be submitted securely online with our Online Request for Information Form.
Submit a paper form
Print and complete an Authorization for Use or Disclosure of Protected Health Information release form prior to your visit.
Mail or fax completed paper form to:
Health Information Managements Systems
LMH Health
325 Maine
Lawrence, KS 66044
Fax: 785-505-5222
If you need to amend your medical records, download, print and complete a Request for Amendment of Protected Health Information (pdf).
If you are unable to visit our office, mail or fax completed paper form to:
Health Information Managements Systems
LMH Health
325 Maine
Lawrence, KS 66044
Fax: 785-505-5222
An advance directive is a document that states an individual's healthcare wishes if they become unable to speak for themselves. Advanced directive documents to be incorporated into your medical record can be emailed to advancedirectivehims@lmh.org
This booklet describes advance directives in more detail and includes easy-to-complete forms:
Download Advance Directives - English (pdf)
Download Directivas anticipadas - Spanish (pdf)
As a patient of LMH Health hospital and physician clinics, you can access your electronic health information in a secure internet portal with My Patient Portal. This service is free. Learn more and register today. If you need assistance registering for My Patient Portal, please email medicalrecords@lmh.org.
