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Patients & Visitors Medical Record Request
request medical records

Medical Record Request

​​​​​​​​​​​​​​​To request a copy of your medical records from SSM Health Good Samaritan Hospital - Mt. Vernon or St. Mary's Hospital - Centralia, the Authorization for Release of Protected Patient Health Information form must be filled out and returned to the Health Information Management (HIM) Department.

You can receive your Good Samaritan Hospital - Mt. Vernon or St. Mary's Hospital - Centralia medical records in one of two ways:
  1. ​By mail – via the U.S. Postal Service
  2. By picking them up in person after making arrangements with Health Information Management (HIM).

Instructions For Submitting Request 


Good Samaritan Hospital​

St. Mary's Hospital

  1. Print and fill out the Form
  2. Mail to:
    ATTN: HIM Department
    1 Good Samaritan Way
    Mt. Vernon, IL 62864

  1. Print and fill out the Form.
  2. Mail to:
    ATTN: HIM Department
    400 N. Pleasant Ave.
    Centralia, IL 62801

  1. Print and fill out the Form.
  2. Fax to: 618-899-4764
  1. Print and fill out the Form
  2. Fax to: 618-436-8016​


​Call: 618-899-2030 Select Option 1


Call: 618-436-8788

Once We Receive Your Completed Authorization Forms...

After the authorization form is filled out and received by our office we will send a copy of your medical records via U.S. Mail. The medical records may also be picked up by making arrangements with HIM. We do our best to expedite all requests, but in some instances an can take up to 30 business days to complete the request. 


​You can sign up to view your or your child's medical records from your computer or any smartphone. Learn more about this free and convenient service for our patients. There are some limitations to what can be viewed in MyChart

Frequently Asked Questions

​Do I need to send any sort of documentation along with the form? 

St. Mary's Good Samaritan takes patient privacy very seriously. Therefore, a copy of the patient’s legal guardian's ID is required to request medical records. We need this identification to verify that you are authorized to request the patient’s records. This can be a state-issued ID, birth certificate, etc. If you have any questions about what type of ID is accepted, please contact HIM. 

How will I receive the records?

You can receive the medical records in one of two ways:
  1. ​By mail: via the U.S. Postal Service 
  2. By picking them up in person: after making arrangements with HIM 

Can I have the records sent along to someone else like a physician or specialist?

Yes. In the second section of the authorization form, there is a place to indicate that you are authorizing Good Samaritan Regional Health Center or St. Mary's Hospital to disclose the medical records to a third party.

If so, what information do you need from the third party: address, phone, etc.?  

In the case of disclosing medical records to a third party, we would need the name, address, phone, and fax (if applicable) of the third party. We would also need the relationship of the third party to your child (school, physician’s office, etc).

Does it cost money to request my medical records?

For personal requests, the cost depends on the number of pages requested. Printing costs start at 99 cents per page for smaller requests and as low as 33 cents per page for larger requests. You can also opt to have records stored on a DVD, which is half the cost of printing. 

For requests being sent to a third party (i.e. continued care, insurance companies, or legal counsel), the fee will be paid for by that third party. Please be sure the third party is properly listed in the second section of the Authorization form.   

What sort of payment do you take?

A bill will be sent to you directly from Healthport with contact information and instructions on how to pay for your copies. Payment for your records is not handled by the staff at the hospital/HIMS department who is setting up your request for copies​.​

How can I be sure this is safe? 

Providing correct information on the Authorization form is the first step in protecting your child’s confidential health care information. Be specific regarding the documents and dates that are to be released. Also, make sure any third party information listed on the Authorization form is correct; we will only release your child’s records to the parties listed on the form. We also use an encrypting method to ensure the security of your child’s private health care information.