REQUEST FOR DECEASED PATIENT RECORDS REQUEST FOR DECEASED PATIENT RECORDS 2026

1. Click ‘Get Form’ to open the REQUEST FOR RELEASE OF DECEASED INDIVIDUAL’S ARCHIVED RECORDS in the editor.
2. Begin by entering the name of the deceased individual, including any maiden names, along with their date of birth (D.O.B) and date of death (D.O.D).
3. Fill in your details as the requester, including your name, relationship to the deceased, address, phone number, and city/state/zip code.
4. Specify the date range for which you are requesting Protected Health Information by filling in the start and end dates.
5. Select the types of records you wish to request by checking the appropriate boxes such as Discharge Summary, Psychological Assessment, etc.
6. Provide a brief explanation for the purpose of this disclosure in the designated section.
7. Sign and print your name as a legally authorized representative and indicate your authority to act on behalf of the deceased. Remember to attach supporting documentation.
8. Once completed, save your form and mail it along with all required documents to the Health Information Department at Montana State Hospital.

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