Request a Medical Record

To receive a copy of your medical record, you must submit a written request to the Health Information Management Department (HIM).  A letter of authorization form signed by the patient or parent (if the patient is under 18 years of age) must accompany all requests for release of information.

If you are the next of kin, you will need to complete the Medical Records Request form with the Right to Access form and a copy of the death certificate.

If you are a doctor’s office, please use the MD Request form.

Your requests must include the following:

• Patient’s full name
• Patient’s date of birth
• Hospital visit dates for information being requested
• Purpose of request
• Name and address of facility or person to receive the medical record copies
• Patient signature (or signature of patient’s legal guardian, if the patient is under 18 years of age)
• Date of request
• Daytime phone number

Send the completed letter or authorization form to:

Attn: Health Information Management Department
Delta Specialty Hospital
3000 Getwell Rd
Memphis, TN 38118

Requests can also be faxed to the fax number below:

Fax Number: 901-369-8563

To contact the Health Information Management Department please call:

Phone Number: 901-369-8550

Process time for requests is 10-15 business days from the date your request is received.