Medical Forms

For your convenience, you can download several forms on this page and fill them out at your leisure to prepare for requesting a copy of your medical record, directing medical care for yourself, or tracking the medications that you take and how frequently you take them.

Request a Copy of Your Medical Record

Once Kaweah Delta's Health Information Department has received your request, it can take anywhere from 3 - 5 days to process it. To request a copy of your medical record, please complete the “Authorization to Disclose Health Information” form below: 
Download English Authorization Form
Download Español Authorization Form

Bring the completed form, along with photo identification to:
Health Information Management Department
Acequia Wing Lobby (Parking available on Acequia Avenue)
305 West Acequia Avenue
Visalia, CA 93291

Monday – Friday: 8 a.m. – 4:30 p.m.
Open during lunch hours.
Closed on holidays.
Phone:  559-624-2218

Processing times may vary depending on the complexity of your request, however in most cases authorizations are completed within two to three business days from the date of receipt. 

Questions: Click HERE to send an e-mail to Kaweah Delta's Health Information Department. 

Get an Advance Directive

Download English AHD
Download Español AHD

Click HERE to watch a short video describing what an Advance Healthcare Directive is and what it means to you and your family.

What is an Advance Healthcare Directive?

Advance Healthcare Directive (AHD) is a document with special instructions, prepared in advance, designed to direct medical care for you if you are unable to do so. This is helpful for adults of all ages and is useful in situations where you cannot speak for yourself. Completing the AHD does not mean you do not want treatment. It is designed to give specific direction to your physicians and your family.

Why do I need one?

An AHD can help put your mind at ease and enhance your doctor’s and your family’s knowledge regarding your wishes for medical treatment. An AHD can prevent treatment that you would not choose for yourself and decrease feelings of helplessness and guilt for your family.

What should I include in my AHD?

  • Consider what is important to you—what are your goals for medical treatment?
  • What things are important to you? Independence, self-sufficiency things of that nature.
  • How do you imagine you would handle serious illness or disability?
  • How might your personal relationships affect medical decision-making?
  • What role should doctors and other health professionals play in such decisions?
  • What kind of living environment is important to you if you become seriously ill or disabled?
  • What role do religious beliefs play in your decisions?
  • Should cost to your family be a part of the decision-making process?

In considering these questions you should choose someone you trust to carry out these wishes. It is also recommended that you select an alternate. Carefully go over your wishes with them and ask them if they would be willing to follow through with your choices.

The Med Form

Download The Med Form in English

Download the Med Form in Spanish


Why do I need a Med Form?

The Med Form helps you and your family track medications you are taking from prescription to over-the-counter herbals and vitamins. This document is designed to provide physicians and others with a current list of all of your medicines. By sharing The Med Form with their providers, patients become active participants in the healthcare team.

What will the Med Form do?

  • Help you and your family members remember all of the medications you are taking
  • Provide your doctor(s) and other healthcare providers a current list of all medicines, including over-the-counter medicines, vitamins and herbals
  • Detect concerns about medicines by including a comprehensive listing of medications for your healthcare team


Instructions for the The Med Form:

  • Keep The Med Form with you at all times, in case of a medical emergency.
  • Take The Med Form with you to all doctor and other healthcare provider visits (e.g., nurse practitioner or dietitian).
  • Write down all of the medicines you are taking, including over-the-counter medications such as vitamins, herbals and others.
  • Include the name of the doctor who prescribed the medication. You may also write why you are taking the medicine (e.g., high blood pressure, high blood sugar, high cholesterol). If you are not sure why you are taking the medication please write "don't know".
  • When you are discharged from the hospital, someone will speak with you about which medicines to take and which medicines to stop taking. Because patient medications often are changed during hospitalization, it's important that you complete a new Med Form. Take the new form to all doctor visits following your hospitalization to discuss it with him or her.
  • Remember to update your Med Form when your doctor changes, stops or updates your medication.
For more information on Safe Medication Practices (ISMP)  please visit: