Access Your Medical Records
Use this form to request your medical information. Please print clearly and fill out as much information as possible. If unsure of specific dates, please give a range of dates or specific information you are looking for to help us find the correct medical information. Sign and date the form in the designated area on the bottom of the form. Based on the type of request you make, there may be a charge for this service. Have questions? Contact Health Information Services toll-free at 844.203.8777.
Print, complete and mail the form to:
Cleveland Clinic
Attn: Medical Records Department
Mail Code: Ab-7
9500 Euclid Avenue
Cleveland, OH 44195
Or you may fax the completed form to 1.216.587.8043. Please allow 7 - 10 days for processing.
Patient Rights and Responsibilities
In accordance with Avon Hospital's mission and values, as well as applicable laws, accreditation standards, and CMS Conditions of Participation, the hospital staff and its medical staff are committed to providing services on an individualized basis to every person who is sick or injured, regardless of age, race, religion, creed, sex, sexual orientation, national origin, physical or mental challenges, or sources of payment.
Each hospital employee and medical staff member is responsible for ensuring all patients are afforded their rights at all times. A patient or the patient's legally authorized representative shall exercise these rights while receiving care or treatment in the facility without coercion, discrimination, harassment, abuse or retaliation. Any discriminatory behavior by the hospital staff will lead to corrective action.
Avon Hospital Charges
In compliance with state law, Cleveland Clinic provides price lists for each of our hospitals containing charges for room and board, emergency department, operating room, delivery, physical therapy and other procedures, as well as a comprehensive list of all charges that may be incurred, also known as a chargemaster or CDM, and average charges for Diagnosis Related Groups (DRG). The hospital’s charges are the same for all patients, but a patient’s responsibility may vary depending on payment plans negotiated with individual health insurers.
