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(785) 505-5000

Request Your Medical Records

Request copies of your medical record by visiting Health Information Management Systems in the lower level of Lawrence Memorial Hospital, 325 Maine, Lawrence, Kansas. Proper identification will be required. There will be a charge for copies of medical records requested for personal use.

Hours: Monday-Friday, 8:00 am - 5 pm

If you have questions or need assistance, please call 785-505-3093.


Required Forms

For your convenience, please print and complete an Authorization for Use or Disclosure of Protected Health Information release form prior to your visit.

Medical Records Request (pdf)

Medical Records Request - Spanish (pdf)

If you are unable to visit our office, please mail or fax your completed form to:

Health Information Managements Systems
Lawrence Memorial Hospital
325 Maine
Lawrence, KS 66044
Fax: 785-505-5222

Instructions for Information Request - Patient Authorization Form

When picking up copies in person, a photo ID will be required as well as a copy of any legal papers (Power of Attorney, Executor of Estate, proof of custody, etc.) verifying legal right to request such information.

Electronic submissions are not accepted – form must have signature.

  1. Fill in complete patient name, date of birth and social security number. This allows us to locate the proper patient and protect privacy.
  2. PHI-Release To: If copies are for personal use and you are picking them up, please document your complete name and address. If the records are being picked up by another person or mailed, please provide the complete name and address of that person, clinic, hospital etc. you would like us to release the copies to.
  3. Purpose of Disclosure: We are required to document why we release information. Why do you need this information copied or sent? (ie: personal copy, continuation of care by a physician, insurance claim, legal issues, etc.)
  4. Expiration Date: Any date not to exceed 12 months from the date of the request may be used to indicate the active state of this authorization. If no date is provided, the authorization will only be valid for 90 days from the date it was signed.
  5. Documents Requested: Check the box corresponding with the documentation you are requesting. Type of document requested: Mark all documents you would like to receive. An abstract version may be provided which would include all diagnostic (lab, x-ray, EKG, etc.) and typed physician reports. This is generally what most other Health care providers like to have. We prefer to have the admission or discharge dates, however the approximate month and correct year will be accepted if the exact day/date is not known. If you are requesting records for more than one admission or visit, please include each date range you are requesting.
  6. Specific PHI: Drug & Alcohol PHI, HIV/AIDS PHI and Genetic Testing. For each of the categories you must initial yes or no.
  7. Patient Signature: Patient is required to sign and date the form. If the patient is unable to sign or if  request is being made by an authorized representative of the patient (parent of a minor, person named on Power of Attorney, executor of estate, etc.), sign and date the form. Provide printed name, address, etc. Proof of authorization will be required before releasing information.

Witness Signature: A witness may sign and date the form in the event that the patient can only make an X or has given verbal permission.

Mail or fax completed form to:

Health Information Managements Systems
Lawrence Memorial Hospital
325 Maine
Lawrence, KS 66044

Fax: 785-505-5222

Who may request a release of your information

  • If the patient is a competent adult, only the patient may authorize release of records.
  • If the patient is under 18 years of age, the parent or guardian should sign under usual circumstances. A document of proof is required for Legal Custodian. Minor can give authorization when the minor has special legal status as an emancipated minor, i.e., married or previously married, on active duty with the armed forces, ore emancipated by court order, or a self-sufficient minor. b. Consent for treatment of the specific condition is governed by special laws giving the minor the right of consent, i.e, prevention or care of pregnancy, substance abuse and certain communicable diseases.
  • Patient adjudged incompetent: Legal guardian with document of proof required (temporary guardian if appointed by the court.)
  • Durable Power of Attorney for Health Care designee may give authorization.

Requests for deceased individuals

With proper, completed authorization, LMH may disclose a decedent’s PHI to family members and others who were involved in the care or payment for care of a decedent prior to death, unless doing so is inconsistent with any prior expressed preference of the individual that is known to the covered entity. For example, a healthcare provider can describe the circumstances that led to an individual’s death or provide billing information to a decedent’s sibling. This does not include past unrelated medical problems.

If the patient is deceased, the authorization may be obtained in this order:

  • Personal representative appointed by probate court
  • Patient’s family member and, finally, an agent appointed under a durable power of attorney for health care decisions.

My Patient Portal

As a patient of Lawrence Memorial Hospital (LMH), our primary and speciality care providers, you can access your electronic health information in a secure internet portal with My Patient Portal. This service is free. Learn more and register today.

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