Medical Records Policy at West Branch Regional Medical Center
Requesting Copies of Your Medical Records
Requests for medical records must be in writing. Please follow these steps.
- Print out and complete an Authorization for Release of Information. Note: PDF files require Acrobat Reader, version 9 or later. If you experience problems, please download the latest version.
- Mail your completed form to:
Health Information Management
West Branch Regional Medical Center
2463 S. M-30
West Branch, MI 48661
If you do not have access to a printer, you may stop by the above address and fill out a release form there, or call (989) 343-3184 to request a copy of the release form to be mailed or faxed to you.
Important Information About Requesting Medical Records
Records can be released to anyone who the patient authorizes (in writing) to receive such information. The authorization form above can be used to request records for personal use or for continuing medical care.
A valid authorization MUST contain the following information or the request will be returned:
- Patient’s full name and date of birth (list any other names the patient may have had)
- Specific information being requested (i.e., type of report/information and dates of service)
- Purpose for which the information may be disclosed (i.e., personal use, continuity of care, legal matter)
- To whom the information is to be sent (name and address)
- The patient’s signature or a patient’s legal representative’s signature.
Authorizations signed by a representative must be verified. Please include a copy of one of the following documents indicating either:
- Legal guardianship papers, or
- Advance Directive/Healthcare Power of Attorney for patients unable to make healthcare decisions, or
- Designation of Personal Representative, Letters of Authority, which allows the representative to act on the patient’s behalf with regard to personal health information.
- Please note that unsigned requests will not be processed
- Date of the signature
Requests for medical records of deceased patients require a copy of Letters of Authority from the legally-appointed personal representative of the deceased patient.
Please also include your phone number in case we need to contact you for additional information concerning your request.
REQUESTS FOR PERSONAL USE
- Please follow the instructions above
- Please allow reasonable time to process your request. We will contact you in the event we experience unforeseen delays or are unable to fulfill your request.
- Records will be mailed to the address specified on the authorization form, or you may pick up at the hospital if you make arrangements with the Health Information Management Staff. For security reasons, please be prepared to show proper photo identification. To make arrangements for pick-up, please call (989) 343-3184.
REQUESTS FOR CONTINUING MEDICAL CARE
- Medical emergencies will be faxed free of charge directly to a physician or medical facility.
- Continuing care requests are also free of charge and will be mailed to your clinic/physician(s) prior to your appointment (please indicate the date of your appointment on the authorization form so that the copies are received early enough for your physician to review).
- Pertinent information such as radiology/imaging, history and physical, consultations, operative reports, and discharge summaries are routinely provided to the physician for continuing care so there is no need to request these records to be sent.
Certain information requires a special authorization covering sensitive information. This includes psychiatric, drug and/or alcohol abuse, HIV/AIDS, genetic testing. Authorizations for sensitive information must specifically refer to the information that is to be released.
REQUESTS FOR X-RAY FILMS
Please contact our Radiology/Imaging Department for films, at
REQUESTS FOR BIRTH CERTIFICATES/DEATH CERTIFICATES
Please contact the County of Ogemaw, County Clerk’s Office at (989) 345-0215.