Request a Copy of Your Medical Record
You can request a copy of your Atrium Medical Center (Atrium) medical record be sent to you or a designated recipient. A processing fee may be required.
Written Authorization Required
The Authorization for Release of Medical Information/Patient Access Form is your authorization to copy your medical record, or parts of your record, and forward it to another person or organization. Your original signature is checked against our records to validate the request. To open this form, you must have Adobe® Acrobat® Reader, which you can download for free.
You can get this form one of three ways:
- Download it from this web site.
- Call the Medical Records/Health Information Management Services Department at (513) 420-5200(513) 420-5200 to request that the form be mailed to you.
- Stop by the Medical Records/Health Information Management Services Department during regular business hours, 8:00 a.m. - 4:30 p.m., Monday – Friday (You will need to show a valid form of personal identification).
Submitting an Authorization
You can submit your signed copy of the authorization form by mail, by fax, or in person.
Atrium Medical Center
Medical Records—Release of Information
P.O. Box 8810
Middletown, Ohio 45042-9813
The Medical Records/Health Information Management Services Department is located on the second floor of the Compton Center. Park in Lot D and enter through the Professional Building entrance. Take the elevator to the second floor and turn left. Hours are 8 a.m. to 4:30 p.m. Monday - Friday. An appointment is preferred but not required.
Please allow up to 30 working days for your request to be processed. If you stop by the Medical Records/Health Information Management Services Department to pick up your copy, please bring a photo ID.
Who Can Request a Copy?
The following people are authorized to sign for the release of health information:
- Patient (not the spouse)
- Parent (if the patient is younger than age 18)
- Legal guardian (proof of guardianship document must be provided)
- Power of attorney if the patient is unable to sign (legal documentation must be provided)
- Representative of the estate for a deceased patient (legal documentation must be provided, including a copy of the death certificate)
There may be fees associated with retrieving and copying your Atrium medical record. If the medical record is mailed to you, you will be charged for mailing costs. Call (513) 420-5200(513) 420-5200 for more information about processing fees.
Patient Access Fees from a chart or electronic recorded
Pages 1 – 50, $.39
Pages 51 and higher, $.26
There is no charge for copying and mailing a medical record if it is being sent to another health care provider or facility or if it is being used for a social security disability claim. Medical record requests for social security disability claims must be accompanied by a supporting letter from the Office of Social Security.
Content Updated: May 10, 2016
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