Request edit access
Request for Fairmont Regional Medical Center Medical Records
DO NOT CLICK "REQUEST ACCESS" IN THE TOP RIGHT CORNER.  Completing this form is the Request for Access.

Authorization for disclosure of Protected Health Information (PHI).  The information completed below will be stored securely and a notification will be sent to the Medical Records department.  Medical Records will contact you if there are any questions and will notify you when your records are ready.  Due to the large volume of requests, this process can take up to 90 days.

NOTE: If you have already completed a paper form with the Medical Records office, you do NOT need to complete this online form.
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Your Name *
Your Phone Number *
Your Email Address *
Patient Name *
Purpose of Disclosure *
Patient Birth Date *
MM
/
DD
/
YYYY
 Patient Last 4 Digits SSN *
Patient Address *
I hereby authorize Farimont Regional Medical Center to release the following information to (Must include Name/Provider/Facility, phone, street address, city, state, zip and/or fax) *
Which records are you requesting? *
Required
Sensitive Information to be disclosed (if you would like to include this information do not check any of the options)
I understand that *
Required
Comments: (Please share any additional information that is relevant to helping Medical Records fulfill your request.)
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