Eskenazi hospital medical records 2026

1. Click ‘Get Form’ to open the eskenazi hospital medical records in the editor.
2. Begin by filling out the Patient Information section. Enter your full name, date of birth, last four digits of your Social Security number, address, city/state/zip, and day phone number.
3. In the 'Information to be released from' section, specify the provider name as Eskenazi Health and include your physician's name and practice name.
4. Indicate where you want the records sent by selecting one of the options: yourself, attorney, insurance, continuation of care, or other. Fill in the receiving party's details including name, email address, address, city/state/zip, and day phone number.
5. Check the appropriate boxes for the information you wish to release such as discharge summary, lab results, or complete health record.
6. Specify any dates of service if applicable and review the authorization statement regarding revocation rights and potential fees.
7. Choose how you would like to receive your information (paper format or secure electronic form) and initial accordingly. Select an electronic format if desired.
8. Finally, sign and date the form. If a legal representative is signing on your behalf, ensure they provide their relationship to you.

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