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Request Medical Records

To request a copy of medical records for care received at South Bend Clinic, please complete a Patient Request for Access (Form 3000A) and return it in person, via mail, via email or via fax to:

South Bend Clinic
Attn: Release of Information (Health Information Management Department)
211 North Eddy Street
South Bend, IN 46617

Fax:                       (574) 204-7656
Phone:                   (574) 237-9307

Email address:      HIMdept@southbendclinic.com
A Patient Request for Access form can also be returned to your nearest South Bend Clinic facility, where it will be forwarded to HIM, Main campus.

The Patient Request for Access Form

The Patient Request for Access form is available in the Downloads box at the bottom of the page, along with instructions for completing the form.  South Bend Clinic retains patient records for 10 years.  

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.

Continuation of Care with other Providers

All Healthcare facilities requesting medical records must fax a request to South Bend Clinic at (574) 204-7656. Please send the patient name, date of birth and information you are requesting on your fax coversheet and we will fax records back to you. All large volumes of documentation will be mailed and not faxed.

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.

Patient Request for Access form

Form

English

Form Instructions

English

The following fees apply (indicated below) to process your request and you will receive an invoice along with your records.

Fees (first 15 pages free of charge, then)

  • Pages 1 thru 10 – each page $1.00
  • Pages 11 thru 50 – each page $.50
  • Pages 51 plus - $.25 (with a CAP of $25 for individuals and a CAP of $35 for family transfers)
  • Plus postage and tax

The South Bend Clinic Main Campus Health Information Management Department will process requests Monday through Friday through our HIM Customer Service Window from 8:00a.m. to 5:00 p.m.