Medical Records - Firelands Regional Medical Center 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter your name, date of birth, street address, medical record number, city/state/zip, phone number, email address, and fax number as required.
3. In the 'Authorization' section, specify the records you wish to release by checking either 'Hospital Records Only' or 'Physician Office Records Only'.
4. Complete the 'To be released TO' section by providing the recipient's name, address, city/state/zip, phone number, and fax number.
5. Indicate the purpose of release/disclosure by selecting from options like 'Continuity of Care', 'Request of Patient', or specifying another reason.
6. Select which information you want to be released by checking all applicable boxes under 'Information to be released'.
7. Finally, sign and date the form at the bottom. Ensure that you include your relationship to the patient if you are not the patient themselves.

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