Release of Information

To request a copy of your medical records please complete the authorization form. Fill the form out as completely as you can. Be sure to include the organization or person along with the address of where you would like your records released. You may print out the form, fill it out, sign and date it and return to Madison Regional Health System by mail or fax. Or you may fill out the PDF and submit via email.

Release of Information Authorization Form (PDF)

Note: You will need a PDF Viewer such as Adobe Reader to access the PDF document.

Madison Regional Health System
Attn: Release of Information
323 SW 10th St
Madison, SD 57042

Fax: (605) 256-6469 Attn: Release of Information


There may be occasions when you want to give another person the ability to discuss your health information at Madison Regional Health System with Madison Regional Health System personnel (appointments, billing, treatment, diagnosis, prescriptions, etc.).

The authorization for discussion regarding treatment form will allow discussion only. This does not authorize release of medical records. For release of medical records please use the form above.

Authorization for Discussion Regarding Treatment (PDF)

Requests will be processed in the order it was received.

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