Ohio Authorization For Release of Medical Information
Download the document to the computer for easy use
There are more pages to preview,Read on

PRINT FORM

AUTHORIZATION FOR RELEASE
OF MEDICAL INFORMATION
FAMILY NAME:
To request medical records for yourself or your living relatives, this form should be completed by the individual for whom records are requested. For
deceased relatives, this form should be completed by the individual's next of kin or the executor of the estate.
Medical records are requested for:

born on
Last Name

First Name

who is: (check one)

Living

From:

Middle Initial
Deceased

SS#:
Month / Day / Year

If deceased, please include date of death:
Month / Day / Year

The Ohio State University Medical Center
James Cancer Hospital
The Ross Heart Hospital
Clinic
Other [Provide the name, city, and state of the hospital(s) where treated.]

The following medical information regarding my hospitalization, care and/or treatment on the following dates:
to

as an

Surgical report

Pathology report

Please provide my:

Inpatient

Outpatient

Chart summary

Emergency Dept.

Paraffin-embedded tumor block & matching H &