Patient Information

Access Your Medical Records

Use this form to request your medical information. Please complete in full. Based on the type of request you make, there may be a charge for this service.

• Authorization for the Release of Protected Health 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. Please make a copy of your photo ID as well.

Print, complete and mail the form and copy of photo ID to:
Health Information Management Union Hospital
659 Boulevard
Dover, OH 44622

Or you may fax the completed form and a copy of your photo ID to 330.364.0868.

For questions or for more information, call 330.343.3311, ext. 2326 during office hours, Monday - Friday, 7:30 a.m. – 4 p.m.