Medical Records Requests
A patient, or his/her legal representative, may inspect and/or obtain a copy of their medical records, or have copies of medical records sent to another facility.
We require a completed and signed Authorization for Release of Health Information form before releasing any documents to anyone, including the patient.
If you have questions about this process, please feel free to contact the Health Information Management department directly at 419-557-5552.
To Request a Copy of Your Medical Records
- Print the form: Authorization for Release of Medical Information or fill out the form at the bottom of this page.
- The form must be completed, dated and signed by the patient.
- We ask that you specify what components of your medical records you wish to obtain.
- Photo ID is required (records will not be released without this).
- One additional form of ID (such as a credit card, Social Security card, utility bill or library card) are required.
- Individuals other than the patient (such as a guardian or a proxy under a power of attorney) must have documentation of authority to sign.
- Please note: Your request may take up to 30 days to process.
- Did you know that for lab results, radiology results, and cardiologist reports, you can visit your patient portal, My Health eChart? Sign up here or contact our Patient Portal Coordinator at 419-557-7916.
- Health Information Exchange Opt Out Form
If you have any questions regarding release of health information, please call 419.557.5552.
Please mail form to:
North Coast Professional Group, LLC., dba
Firelands Physician Group
HIM Department- ROI
1111 Hayes Ave.
Sandusky, OH 44870
Fax form to:
Attn: Release of Information
Medical Records Office Hours
Monday to Friday, 8 a.m. to 4 p.m.
Form to Request Medical Records