Release of Information

Requesting Your Medical Records

The Good Samaritan Society is dedicated to protecting the privacy and security of health information while ensuring its availability for continued medical care, payment, personal needs or other appropriate uses. Good Samaritan Society locations assist with processing requests from residents, clients or third parties with appropriate authorization to receive medical records.

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Request records by mail, fax or email

You can submit a request for medical records to the Good Samaritan Society location where care was provided. Your request will be processed by the location’s Health Information Management Department or designated person. You can fill out a new written request or forward us an authorization already signed by the resident/patient.

  1. Download and print the Good Samaritan Society’s authorization form.
  2. Authorization forms should be as complete as possible. Missing information may delay processing your request.
  3. Send completed form to the Good Samaritan Society location in one of the following ways:
    • Mail to the respective Good Samaritan Society location and include: “Attn: Health Information Management Department”
    • Fax to the respective fax number and include: “Attn: Health Information Management Department”

You may also drop the form off in person at the Good Samaritan Society location. Ask for a member of the Health Information Management team or someone who can help you obtain a copy of your medical records.

Contact information

A directory of Good Samaritan Society locations is available here.

To send Release of Information form to corporate Health Information Management Department, email:

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Frequently Asked Questions

  • Can I view or get copies of my medical record?

    For access to your medical record, contact the Good Samaritan Society location where you received care. You may also view your medical record by appointment at the same Society location.

  • Who can sign the authorization form?

    Authorization forms must be signed by the resident/patient or their legal representative or guardian.

  • How can I request access to someone else’s medical records?

    A family member requesting a copy of their loved one’s medical records must have either the resident/patient sign the authorization form or provide legal paperwork stating they are the legal representative or guardian.

    Authorized professional third parties requesting multiple resident/patient information without a signed authorization should submit a health information exchange (HIE) request for access to Good Samaritan Society resident/patient data or medical records. Authorized parties may include:

    • Health care providers seeking electronic access to medical records of resident/patient data
    • Research organizations
    • Health insurance companies submitting a new request for medical records or member data
  • How can I get the medical records of a deceased resident or patient?

    If a resident/patient is deceased, the authorization must be signed by the court-appointed legal representative of the estate.

    In some states, a surviving spouse, adult child, parent or other next of kin may have authority to request medical records. This is dependent on specific state law.

  • How much does it cost to get my medical records?

    There is no cost for copies of medical records given directly to the resident/patient or another health care provider.

  • How long does it take to get my medical records?

    Once all information is received and validated, we will process requests as quickly as possible. For urgent needs, please contact the Good Samaritan Society location to discuss special arrangements.

  • Can providers not associated with the Good Samaritan Society request my medical records?

    Yes. Health care providers not associated with the Good Samaritan Society who are providing you care can request your medical records by contacting the Good Samaritan Society location.

  • Who can pick up copies of my medical records?

    If someone other than the resident/patient will be picking up copies of medical records, please let us know in advance. The person picking up the medical records may be required to verify identity prior to taking the medical records.