Medical Records Requests
A patient, or his/her legal representative, may inspect and/or obtain a copy of their medical records, or have copies of medical records sent to another facility.
We require a completed and signed Authorization for Release of Health Information form before releasing any documents to anyone, including the patient.
If you have questions about this process, please feel free to contact the HIPAA / Release of Information department directly at 419-557-7435.
To Request a Copy of Your Medical Records
- Please fill out and print the form: Authorization for Release of Medical Information.
- The form must be completed, dated and signed by the patient.
- We ask that you specify what components of your medical records you wish to obtain.
- Photo ID is required (records will not be released without this).
- One additional form of ID (such as a credit card, Social Security card, utility bill or library card) are required.
- Individuals other than the patient (such as a guardian or a proxy under a power of attorney) must have documentation of authority to sign.
- Please note: Your request may take up to 30 days to process.
- Did you know that for results and reports (except pathology), you can visit your patient portal, My Health eChart? Sign up here or contact our Patient Portal Coordinator at 419.557.7916.
- Health Information Exchange Opt-Out Form
- To request a copy of your medical records email firstname.lastname@example.org
If you have any questions regarding the release of health information, please call 419.557.7435.
Please mail the form to:
Firelands Regional Medical Center
HIPAA/Release of Information Department
1111 Hayes Ave.
Sandusky, OH 44870
Fax form to:
Attn: Release of Information
Amend Your Record
Release of Medical Records May Be Contacted
Monday to Friday, 8 a.m. to 4 p.m.