Patient Medical Records

To request your medical records, you may complete the form below and email it, mail it, or fax it to us. If you don't want to fill out the form below, you can send a written request complete with the following information:

Patient's full name and date of birth (list any other names the patient may have had)
Telephone number
Medical Record Number (if available)
Specific information being requested (e.g., type of report/information and dates of service, etc.)
Purpose for which the information is being disclosed
To whom the information is to be sent (name, address, and phone)
Authorizations are good for one year from signature date unless otherwise specified
The patient's signature or a patient's legal representative's signature. Authorizations signed by a representative must contain a copy of the guardianship papers or power of attorney
Date of the signature

All written requests should be mailed to:

Clara Barton Medical Center
Attn: Health Information Management (HIM)
250 West 9th Street
Hoisington, KS 67544

Phone: (620)653-5092 | Fax: (620)653-2671
Email: HIM@cbhks.com

Your request will be processed within 30 days, and will be sent to you, or you may pick up your medical records in our office between 7:00 am and 5:00 pm.

Processing Fee: We will notify you by phone in advance if there will be a charge for your records.

If you would like to have another facility release your records to Clara Barton, you can fill out this form and take it or send it to that provider/facility.