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
· 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:

$2.73 per page (pages 1-10)
$ .57 per page (pages 11-50)
$ .23 per page (page 51 and more)
No records search fee

* 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).

Copies:

• No Records search fee
• For data records on paper
   $2.73 per pages 1-10
   $0.57 per pages 11-50
   $0.23 per pages 51 and higher
  
  For data recorded other than on paper,
     $1.86 per page
   

Fee schedule made by someone other than the patient or patient’s representative. (for example an attorney or insurance company)

Copies:

• $16.78 records search fee
• For data records on paper
   $1.11 per pages 1-10
   $0.57 per pages 11-50
   $0.23 per pages 51 and higher
  
  For data recorded other than on paper,
     $1.86 per page

CERTIFICATION (Notarized): $2.00
CHART VIEW: $10.00
CONTINUITY OF CARE: No Charge

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 at (740) 687-8264 or (740) 687-8265 to speak to a Release of Information Specialist.