Medical Records Request by Client or Organization

Medical Records Request by Client or Organization

This is only required if you are requesting a copy of your medical records from HWS.

Please Note: printed records will cost a fee in accordance with the Ohio Department of Health's Medical Records Price Index

Date of Request*

Client First Name*

Client Last Name*

Name of Individual or Agency Requesting Records*

This should be YOUR NAME and, if applicable, the name of the agency/organization you are with.

Please select the type of records that you are requesting*

Select all types that apply

Select

Date Range of Requested Records*

Please enter the date range of the records you are requesting.

Example: July 1, 2024 to September 13, 2024 would be entered as 07/01/24-09/13/24

Method In Which Records Are Being Requested to Be Sent*

Please select how you would like for your records to be sent to you.

Please Note: Printed records will cost a fee in accordance with the Ohio Department of Health's Medical Records Price Index

Select

Destination of Records*

Please provide an email address, fax number or mailing address where you are requesting records to be sent.

Upload Legal Document

This is to upload any Release of Information (ROI) or legal court order that permits you to access this client's information.

Drag and drop files here or

Send me a copy of my responses

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