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Medical Records Request

Community Care 

Community Health Needs Assessment

The DAISY Award

Medical Records Request

In order for our Medical Records Department to process your request for medical records please print, fill out, and sign, then either mail, fax, or hand deliver the form below. If a form is not filled out completely it will be denied. Signature of the requesting patient is required by law. If you are a Durable Medical Power of Attorney for a patient, a copy of the Power of Attorney papers must accompany this form. The standard processing time for records request is 7-10 business days.

If you are requesting records be sent to you, (in accordance with N.D. Century Code Section 23-12-14) the following fee scale will apply.

  • 10 pages or less, no charge
  • 11-25 pages, flat fee of $20.00
  • $0.75 per page after the 25th page

This charge includes any administration fee, retrieval fee, and postage expense.

**The only exception for these charges is for Continuation of Care sent directly to another facility**

If you have any questions, please contact our Medical Records Department at 701-797-2221 ext 7134
The medical records fax number is 701-797-2457

Below is information for North Dakotans on advanced health care planning. This document explains what an advanced directive is and how to fill out the legal paperwork, which is included.

Community Health Needs Assessment

What is a Community Health Needs Assessment?

A community health needs assessment is a way for communities to identifiy, and analyze the specific health needs of their community. This assessment allows communities to prioritize their health needs, make a plan to meet those needs, and then execute the plan. Cooperstown Medical Center completes the Comminity Health Needs Assessment because it is a Critical Access Hospital (CAH) and completion of the assessment is mandated by the Affordable Care Act. All CAHs are required to complete this assessment every three years. There are mulitple ways to asses community health needs, here are a few ways:

  • Stakeholder meetings
  • Community focus groups
  • Surveys
  • Interviews with community leaders
  • Population health and other health-related data

Information taken from Center for Rural Health; University of North Dakota; School of Medicine and Health Sciences

Our 2019 assessment is available to the right by clicking on the link. Also provided for your convenience are our 2016 Community Needs Assessment Implementation Plan, as well as the 2016 and 2012 Community Needs Health Assessment.

Community Care Program

CMC offers assistance to help cover your facility medical costs. To apply for Cooperstown Medical Center’s Community Care program, please download the form below and return to Annie Dewald, HIM Manager/Corporate Compliance, or to the Business Office. The application for Community Care is now available to be filled out below as well. Please be aware that more information may/will be requested before approval of your application. This is a sliding scale fee policy.

Download the Community Care Application or fill it out online below.

Online Community Care Application

It is the policy of Cooperstown Medical Center, to provide essential service regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. Please complete the following information to determine if you or members of your family are eligible for a discount.

The discount will apply to all services received at the clinic and hospital, but not those services or equipment that are purchased from outside, including reference laboratory testing, medications, and x-ray interpretation by a consulting radiologist, and other such services. This form must be competed every 12 months or if your financial situation changes.

  • Please List Spouse and Dependents Under Age 18

  • NameDOB 
  • Please Complete Income and Assets

  • NOTE: Copies of tax returns, pay stubs, or other information verifying income may be required before a discount is approved.
  • This field is for validation purposes and should be left unchanged.

DAISY Award

The DAISY Award was established by the DAISY Foundation in memory of J. Patrick Barnes who died at 33 of ITP, an auto-immune disease. The Barnes Family was awestruck by the clinical skills, caring and compassion of the nurses who cared for Patrick, so they created this national award to say thank you to nurses everywhere.