DOWNLOAD AUTHORIZATION FORM
Spanish language version:
DOWNLOAD SPANISH FORM
Or, you can pick up an authorization in the Medical Records Department, Mon.— Fri., 8:30 a.m.— 4:30 p.m. A picture I.D. is required at the time of the request.
During non-business hours, copies of the authorization and instructions can be found on the wall outside the Medical Records Department at Fairfield Hospital.
Request by mail or by phone
Mercy Health — Fairfield Hospital
Attn: Medical Records ROI
3000 Mack Rd.
Fairfield, OH 45014
Medical Records Department: 513-682-7259
When will I receive a copy of my medical record?
Please allow 30 business days for us to process your request. In some cases, the information you need may be stored at one of our offsite storage locations so additional time may be required to process your request. Please be sure to fill out the authorization form accurately. Inaccurate information on the form may cause delays in providing you with the information you requested.
If your request requires a fee, you will be notified of the fee before the record is sent.