Getting You Copies of Your Medical Records Is Our Pleasure
Download and Print the Medical Release Authorization Form Below:
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 yourself, 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, Monday to Friday 7 a.m.-8:30 p.m. 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 (driver’s license, state ID, employment badge, etc.) to the Medical Records Department, located on the first floor at Fairfield Medical Center.
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, 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 Technician Monday through Friday between 7 a.m. – 8:30 p.m.
If you are attempting to reach a Release of Information Technician between the hours of 7 a.m. – 8:30 p.m., please call 740-687-8264 or 740-687-8265.