Skip to main content.

Release of Patient Information Form


We want to make it as easy as possible for you to obtain your medical records.  An authorization form must be used for all requests for personal health information. 

Please print this form, fill it out completely and take it to your physician’s office or the facility from which you wish to obtain your medical records. Be sure to sign and date the form. Incomplete forms will be returned to you unprocessed. A separate authorization must be completed for each request.

Summa Health System may charge a fee to patients for copies of records based on labor and supply costs as follows:

Pertinent summary = Free
Entire record on paper = $0.10/page
Entire record on CD/Flash drive $6.50

Non-patient requesters (attorneys, etc.) are charged based on amounts allowable by the Ohio Revised Code.  


Options to Request an Appointment

If your situation is an emergency, call 911.