Request Medical Records
Patients who have received care at this facility may request copies of their medical records/health information to be released to themselves or others/third parties. Please see Questions About Medical Records for important information before submitting a request for records. Record requests from patients are handled as priority and will be released in a timely manner.
If you have created a Patient Portal account, you may already have access to the information you need. Click here to access or register for your patient portal.
Requesting your medical records online is an easy, fast, and secure way to receive your information. We recommend online medical requests whenever possible. Just use the button below and follow the prompts.
Request Medical Records Now
If you are not able to use the online request process, download one of the forms below, complete and send to:
Dupont Hospital/Dupont Medical Group
Phone - 260-416-3151 or 260-416-3019
Fax - 260-416-3307
Email - lhreleaseofinformation@chs.net
Mailing Address/Drop-off Address
2520 E Dupont Rd
Fort Wayne, IN 46825
Hours: Monday – Friday, 7 a.m. to 3:30 p.m.
English
Spanish
Questions About Medical Records
Who can request a patient's medical records?
Authorizations must be signed by the patient or the patient's legal representative. If the patient is a minor (under age 18), authorization must be signed by a custodial parent or a legally appointed guardian. Proof of guardianship is required.
What if the patient is unable to sign the authorization?
If the patient is unable to sign by reason of physical or mental disability, authorization may signed by the next-of-kin or legally appointed guardian. Proof of guardianship is required, and must indicate the patient's disability.
How can I receive records for someone who is deceased?
Authorization must be signed by the personal representative of the estate or next-of-kin. If the patient did not expire at the facility, proof of death is required. Additionally, appointment as the personal representative of the estate or status as next-of-kin must be verified.
What types of documentation are needed if I am requesting records for someone else?
If you hold Power of Attorney (POA), are a Healthcare Surrogate or Healthcare Proxy, the related legal forms and court orders must be provided. This may result in additional review and processing times.
Do medical request authorizations expire?
Yes. Authorizations will expire on the date/time or event specified on the release form. A new release form will be required if an older release form does not support the new request for records.
Do medical records include billing information?
No. The Medical Records Department does not have access to billing records or information.
Will there be a charge for copies of my medical records?
There may be a charge for copies of medical records for yourself or a request directed to a third party (excluding continuity of care request). These charges would be in accordance with HIPAA reasonable cost and/or your state law. Contact the HIM Department for questions concerning potential costs.