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St. Louise Regional Hospital

Requesting Medical Records

Complete a release of information form

Patients or their legal representatives can get copies of their medical records, or have copies sent to another facility. To do this, St. Louise Regional Hospital requires a completed and signed form before we can release the records to anyone, including the patient.

  1. Print and complete the Request for Release of Medical Record Information form. This release of information form is available as a Spanish version and a Vietnamese version. (The form must be completed, dated and signed.)
  2. Make sure to specify which parts of your medical records you wish to obtain. Often the discharge summary, operative report and history and physical exam have information needed for continued care.
  3. Requests/authorizations for the following information must be initialed as indicated on the form by the authorized person:
    • Psychiatric Care
    • AIDS/HIV
    • Alcohol/drug abuse

If you have questions about this process or regarding the release of medical record information, please call (408) 848-8615 and choose option 4. 

For information regarding radiology films or the CD library, call (408) 848-8622.

Cost for copy of information

Records requested for a physician or other provider are sent to the provider at no cost. If you would like to obtain a copy for your records the following costs could apply:

  • $6.50 for a copy of the electronic portion of the record.
  • $0.07 per page to reproduce the part of your record that is stored in the paper.
  • If your charges exceed $100, we may require payment before the records are released

For X-Ray or radiology images, the first CD or set of films is free; additional copies cost $15 for CD, or $15 for each film. To contact the Radiology Film/CD Library, call (408) 848-8622.