This form is used to request your medical records. It may be sent to the address listed below or hand delivered. Please note that requests may not be able to be filled immediately.
At this time we are limiting access within the hospital. If you would like to request health information, please complete this form and return it via email to firstname.lastname@example.org.
Download a printable version of the form here.
If you are unable to access this form, or do not have access to email, please contact the Health Information Management department directly at 419-732-4026.