Release for Medical Records
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.
The University of Toledo Medical Center requires a completed and signed Authorization for Release of Health Information form before releasing any documents to anyone, including the patient. In certain cases, a patient's physician, psychologist or social worker may also be required to approve a request.
If you have questions about this process, please feel free to contact the Health Information Management department directly at (419) 383-4982.
To Request a Copy of Your Medical Records
- Print and complete the Authorization for Disclosure of Health Information form.
- The form must be completed, dated and signed.
- We ask that you specify what components of your medical records you wish to obtain. Often, the discharge summary, operative report and history and physical contain relevant information to suit your needs.
- Requests must be specifically signed if requesting/authorizing the following information:
o Psychiatric Care
o Alcohol/Drug abuse
- If you have any questions regarding release of health information, please call (419) 383-4982.
To submit your request once your form is completed:
Please bring form to:
Any UTMC registration area
Mail form to:
UTMC- ROI Office
1015 Research Drive, Mail Stop 1072
Toledo, Ohio 43614
Fax form to:
Attn: Release of Information
Release of Information Charges
- No charges for records released to your physicain for continuing medical care.
- No charges for page count if 7 pages or less.
- If more than 7 pages charges apply beginning with page 1.
- $2.98 per page for 1 -10 pages.
- $0.62 per page for 11-50 pages.
- $0.26 per page for 51 and higher.
- $15 for viewing of records.
- If your charges exceed $100, we require payment before the records are released.
- If an individual other than the patient is picking up the records, then that individual must have an original signed authorization letter from the patient and along with a photo ID. You may also be required to provide additional documentation to show that you have a legal right to request the record set. Examples of these documents include: Letters of Representation; Guardianship Papers; Affidavits of Heir of Law; etc.
- Please allow up to 7-10 business days for your request to be processed. If you indicated the option to pick-up, you will be contacted by the Release of Information Office when your records are ready. A photo ID is required.
- Receive confidential communications of health information.
- Request an amendment and/or correction to protected health information.
- Receive and accounting of disclosures of protected health information.
- Request a restriction on Protected Health Information.
- If you have questions regarding your billing statement, please contact 419-383-7400
- For itemized billing statements, please contact 419-383-4982
- For University of Toledo Physician's Billing Statement, please contact 419-383-7197
Radiology Images/EKG Films/Pathology Slides
If you are requesting radiology images, telemetry tapes or photos, you must contact the department that collected the data.
- You can contact:
o The Radiology Film/CD Library by calling (419) 383-3937
o EKG Film Library by calling (419) 383-3995
o The Pathology Slides Library by calling (419) 383-3470/Histology Slides Library by calling (419) 383-5229