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ST. JOSEPH MERCY
,,, CHELSEA
SAINT JOSEPH MERCY HEALTH SYSTEM
PATIENT REQUEST FOR MEDICAL RECORDS
Health Information Management
775 S. Main Street
Chelsea,
Ml 48118
Phone (734) 593-6310
Fax (734) 593-6315
Patient Name: (Last) ____________ (First) ________ ___ (M.I.)_
Address: (StreeUBox) (City) (State) __ (Zip) __
Telephone: Home ___________ Cell _______ ____ _
Date of Birth: ______ _
I request St. Joseph Mercy Chelsea Hospital to provide me with a copy of my medical records.
INFORMATION REQUESTED
Types and Dates of Records Requested
D Emergency Room Records of:
D Discharge Summary (lnpt) Date(s):
D History & Physical
D X-ray Reports from: to:
D Lab Reports from: to:
D Outpatient Records - Specify type and dates:
D Others
Signature of Patient or Personal Representative
Date Time
If Personal Representative , state relationship: ____________ _ __ _ __ _
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Photo ID Verified
□
Completed by: ___________ _
Date Time
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Form # 7181-020 (rev. 01/03/20 17)
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