Your Medical Records

Your Medical Records

Community Memorial Hospital (CMH) in Hicksville, Ohio, is committed to ensuring the privacy and security of patient health information.  For most disclosures other than the usual course of treatment, payment, or health care operations, we must obtain the individual’s authorization before using or disclosing the individual’s protected health information (PHI). 

If you have been a patient at Community Memorial Hospital in Hicksville, Ohio, you can request a copy of your medical records by calling the Health Information Management (HIM) department at 419-542-5664 between 8:00 a.m. and 4:30 p.m., Monday through Friday. How you intend to use your medical records determines your next step.

Requesting Records for a CMH Physician:

If you are requesting records for a physician who is a member of the CMH medical staff, our HIM department can send your records directly to that physician.  A signed written authorization is needed with the patient name and the name of the physician to whom we should send your records.

Requesting Records for Other Physicians or Medical Facilities:

If the records you are requesting are for a doctor who is not a member of the CMH medical staff, or if they are for another health care facility, they can be obtained only by written request with your authorization. After calling the HIM office to request your records, you may either mail your written request with authorization or sign an authorization form in the HIM department. We will mail the requested records for you at no cost. If you prefer, your medical records may be obtained directly from the HIM Department at CMH. There is a charge for all records hand carried out of the hospital.

Requesting Records for Personal Use:

You can obtain a copy of your medical records for personal use. We charge a flat fee of $3.07 for the first 10 pages, $.64 per page for pages 11-50, $.26  per page for all pages over 50. Request and obtain medical records for personal use as you would request them for physicians and medical facilities outside of CMH (see above). Cash, Check, or Money Order accepted for payment.

Non-CMH Records:

We can release records for CMH patients only. Our medical records personnel in HIM do not have access to medical records from any other hospital. Our HIM department also handles all CMH-employed physician office records.  Please specify on your request if you are requesting physician office records.

Printable Authorization for Release of Medical Records

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