Medical Records

Authorization for Release of Medical Information Forms

• Premier Health Hospitals
• Premier Health Hospitals - Spanish
• Premier Physician Network
• Fidelity Health Care
• Samaritan Behavioral Health, Inc.

Medical Record Amendment Request Forms

• Premier Health Hospitals
• Premier Physician Network
• Samaritan Behavioral Health, Inc.

In MyChart

Premier Health MyChart is the easiest way to access and manage your health information online, including requesting a copy of or sharing your medical records.

To request a formal copy of your hospital records through MyChart:

1. Go to the Sharing Hub (you will be prompted to login.)
2. Select a sharing option and follow the steps. 
3. When your records are ready, you can find them in the Document Center under My Record.
4. If you request a paper copy, a small fee may apply.

Don’t have  MyChart account? Create a new MyChart account now.

Other Options

Download and print an authorization for release of medical information form, or contact the hospital to request one be sent to you. You can also download the authorization for release of medical information in Spanish.

Contact information can be found in the Premier Health Hospitals Contact Information section.

All forms must be signed before they can be processed. You can submit your form:

• By email: If you return your form by email, the content of your outgoing message will not be secured by encryption and could be accessed by others outside Premier Health. Your medical records will be emailed to you through a secure channel.
• By fax: Healthcare providers can also request records by fax. The request must include:
  • The patient’s demographics and records being requested, such as test results, notes, and discharge summaries.
  • The location of treatment or records you are requesting from.
• By mail
• In person

The best way to review your records is to request a formal copy of your records.

Premier Health hospitals also offer you the option to schedule an appointment to review your hospital medical record in person. Records must be reviewed in the presence of Medical Records employees. See the Premier Health Hospitals Contact Information section to contact the hospital medical records department at the hospital where you received service to make an appointment.  

• You must bring your photo ID.
• You may not remove any part of the record from the folder or make any changes.
• You can get a copy of your record for a fee.

Download and print an amendment request form, or contact the hospital to request one be sent to you.

Contact information can be found in the Premier Health Hospitals Contact Information section.

Send your completed and signed form to the Premier Health hospital where the amendment needs to be made. Forms can be submitted:

1. By email
2. By fax
3. By mail
4. In-person

You have the right to request a record of certain times we shared your protected health information/medical record over the past six years. To make a request, you must submit a written and signed (by you or your representative) document.

Your first request within a 12-month period is free. If you make additional requests within the same 12 months, a fee will apply.

Send your signed request to the health information management/medical records department of the hospital where you received service.

Requests can be submitted:

1. By email
2. By fax
3. By mail
4. In person

Contact information can be found in the Premier Health Hospitals Contact Information section.

Premier Physician Network

Mailing Address: Find your practice by practice name or provider name for the practice address.
Email Address: PPNROI@premierhealth.com
Phone: Find your practice by practice name or by provider name for the practice phone number.
Fax: (937) 641-7274

Find Your Practice

By practice name:

Go to our practice listing page and click on the name of your practice. Once on the practice website, click on Contact Us in the right navigation to find the practice address and phone number.

OR

By provider name: 

1. Using site search on PremierHealth.com, search for your provider’s name.
2. Under PPN Provider matches, click on their hyperlinked name.
3. Scroll down on the profile and click on the Practice Website link. 
4. Click on Contact us in the right navigation to find the practice address and phone number.

Online

Use our secure, online medical records request website to authorize records to be released from any PPN office to yourself or another office.

Your medical records will be emailed to you through a secure channel.

Other Options

Download and print an authorization for release of medical information form, or contact your practice to request one be sent to you.

Contact information can be found in the Premier Physician Network Contact Information section.

All forms must be signed before they can be processed. You can submit your form:

• By email: If you return your form by email, the content of your outgoing message will not be secured by encryption and could be accessed by others outside Premier Health. Your medical records will be emailed to you through a secure channel.
• By fax:Healthcare providers can also request records by fax. The request must contain:
  • The patient's demographics and records being requested, such as test results, notes, and discharge summaries.
  • The location of treatment or records you are requesting from.
• By mail
• In person

You can review your medical record by requesting a copy. If you have questions about accessing or reviewing your records, please contact your practice for assistance using the Premier Physician Network Contact Information section.

Download and print an amendment request form, or contact your practice to request one be sent to you. Send your completed and signed form to the practice where the amendment needs to be made.

Contact information can be found in the Premier Physician Network Contact Information section.

Forms can be submitted:

1. By email
2. By fax
3. By mail
4. In person

You have the right to request a record of certain times we shared your protected health information/medical record over the past six years. To make a request, you must submit a written and signed (by you or your representative) document.

Your first request within a 12-month period is free. If you make additional requests within the same 12 months, a fee will apply.

Send your signed request to your practice where you received service. Requests can be submitted:

1. By email
2. By fax
3. By mail
4. In person

Contact information can be found in the Premier Physician Network Contact Information section.

Fidelity Health Care

Mailing Address:
3170 Kettering Blvd.
Dayton, OH 45439
Email: FidelityMedicalRecordsDepartment@premierhealth.com
Phone: (937) 208-6400(937) 208-6400 or (800) 946-6344(800) 946-6344
Fax: (937) 641-7285
Hours of operation: Monday through Friday, 8 a.m. to 5 p.m.

Download and print an authorization for release of medical information form, or contact Fidelity Health Care to request one be sent to you.

Contact information can be found in the Fidelity Health Care Contact Information section.

All forms must be signed before they can be processed. You can submit your form:

• By email: If you return your form by email, the content of your outgoing message will not be secured by encryption and could be accessed by others outside Premier Health. Your medical records will be emailed to you through a secure channel.
• By fax: Healthcare providers can also request records by fax. The request must contain:
  • The patient’s demographics and records being requested, such as test results, notes, and discharge summaries.
  • The location of treatment or records you are requesting from.
• By mail

You can review your medical record by requesting a copy. If you have questions about accessing or reviewing your records, please contact the Fidelity Health Care Medical Records Department using the Fidelity Health Care Contact Information section.

Contact Fidelity Health Care to request an amendment request form be sent to you. Send your completed and signed form to the Fidelity Health Care medical records department. 

Contact information can be found in the Fidelity Health Care Contact Information section.

Forms can be submitted:

1. By email
2. By fax
3. By mail

You have the right to request a record of certain times we shared your protected health information/medical record over the past six years. To make a request, you must submit a written and signed (by you or your representative) document.

Your first request within a 12-month period is free. If you make additional requests within the same 12 months, a fee will apply.

Send your signed request to the Fidelity Health Care medical records department. Requests can be submitted:

1. By email
2. By fax
3. By Mail

Contact information can be found in the Fidelity Health Care Contact Information section.

Download and print an authorization for release of medical information form, or contact Samaritan Behavioral Health, Inc. to request one be sent to you.

Contact information can be found in the Samaritan Behavioral Health, Inc. Contact Information section.

• By email: If you return your form by email, it will not be secured by encryption and could be accessed by others outside Premier Health. Your medical records will be emailed to you through a secure channel.
• By fax: Healthcare providers can also request records by fax. The request must contain:
  • The patient’s demographics and records being requested, such as test results, notes, and discharge summaries. 
  • The location of treatment or records you are requesting from.
• By mail
• In person

You can review your medical record by requesting a copy. If you have questions about accessing or reviewing your records, please contact the office where you received service using the Samaritan Behavioral Health, Inc. Contact Information section.

Download and print an amendment request form, or contact the office where you received service to request one be sent to you. Send your completed and signed form to the office where the amendment needs to be made. 

Contact information can be found in the Samaritan Behavioral Health, Inc. Contact Information section.

Forms can be submitted:

1. By email
2. By fax
3. By mail
4. In person

You have the right to request a record of certain times we shared your protected health information/medical record over the past six years. To make a request, you must submit a written and signed (by you or your representative) document.

Your first request within a 12-month period is free. If you make additional requests within the same 12 months, a fee will apply.

Send your signed request to the office where you received service:

1. By email
2. By fax
3. By mail
4. In person

Contact information can be found in the Samaritan Behavioral Health, Inc. Contact Information section.