Request edit access
Request for 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 30 days.
NOTE: If you have already completed a paper form with the Medical Records office, you do NOT need to complete this online form.
Your Phone Number
Patient Birth Date
Which records are you requesting?
Physician Records (OVMG)
Hospital Records (OVMC/EORH)
Information to be disclosed
Medical Record Abstract (includes Discharge Summary, RD Information, History & Physical, Operative Reports, Consultations, Radiology, Laboratory, and other Tests, and Clinic Notes)
Use CD/DVD where possible. Remaining records will be printed.
I understand that
My health record(s) will not be released or obtained unless permission is granted by my signature/agreement on this authorization.
Comments: (Please share any additional information that is relevant to helping Medical Records fulfill your request.)
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