Medical Release Authorization

Below you can download and print the Medical Release Authorization.

Authorization for Medical Information Form (PDF)

Download and complete the form in its entirety to include name, date of birth, types and dates of service, and to whom you wish your information to be sent or released. To avoid delays in your request, please be certain to complete all fields of the form.

Make sure to sign and date the authorization. If requesting information for someone other than your self, you will need to provide one of the following:

  • Healthcare Power of Attorney (Restrictions may apply)
  • Executive of Estate paperwork and Death Certificate
  • Custody papers (if applicable)

The Authorization for Release of Information form may be mailed to:

Fairfield Medical Center
Attn: Medical Records / Release of Info

401 North Ewing Street
Lancaster, Ohio 43130

or faxed to: 740-687-8935

Or you may visit us at the Medical Records Department, on the first floor, Mon-Fri, 8:00 AM- 11:00 PM. Please be sure to include the address of the person to whom you wish the records to be sent.

Include the phone number and fax number, if you wish the information to be sent to a physician. We typically only fax records to physician's offices, if they are needed sooner than can be sent by mail.

If you wish to personally pick-up the copies, please bring a photo ID (drivers license, state ID, employment badge, etc.) to the Medical Records Department, located on the first floor at Fairfield Medical Center.

Charges

Charges for copies of medical information are applied according to Ohio law and are as follows for our patients:

* There is no charge for copies when sent to a physician for continuity of care.

Fee schedule for a patient or a patient’s personal representative. (for example a minor patient’s parent or other person acting as a guardian, a person with durable power of attorney for the health care for a patient, or the executor of a patient’s estate).

2013 ROI Copy Fees

For paper records
 
Pages 1-10
$2.98/page
Pages 11-50
$0.62/page
Pages 51+
$0.26/page
For data recorded other than on paper
$2.04/page

For requests made by someone other than the patient or patient’s personal representative:

  • An initial fee to compensate for the records search $18.34.
For paper records  
Pages 01-10 
$1.20/page
Pages 11-50 $0.62/page
Pages 51+
$0.26/page
For data recorded other than on paper $2.04/page

Chart View
$10.00

These fees are in compliance according to the Ohio Revised Code 3701.742

Request Turnaround: Requests are typically completed in the order that they are received. We are required by law to send your information within 30 days of receipt of your request (60 days for off-site records), with the allowance of one 30-day extension.

If you anticipate an urgent need for your medical information (for example, an upcoming doctors appointment) please indicate on your Authorization form, the date by which your doctor will need the information or contact us to speak to a Release of Information Specialist Monday through Friday between 7 a.m. - 9:30 p.m.

If you are attempting to reach a Release of Information Specialist between the hours of 7 a.m. - 3:30 p.m. please call 740-687-8264 or 740-687-8265.

If you are attempting to reach a Release of Information Specialist between the hours of 1:00 p.m. - 9:30 p.m., please call 740-687-8341.