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Release of Medical Information

Release of Medical Information

Although the physical medical record is the property of Lima Memorial Hospital, the information contained within belongs to you, the patient. You have the right to see and get a copy of it.

To obtain copies of your medical records, click on the link below to print the Release of Medical Information Form. Complete the form, paying close attention to the following areas which need completed in their entirety:

  • Patient Name
  • Patient Address
  • Patient Phone Number
  • Patient Social Security Number
  • Patient Date of Birth
  • Date of Service (Approximate if necessary)
  • Type of Information Requested
  • Purpose of Disclosure
  • Sign, Date, and Witnessed

Click Here to Download the Release of Medical Information Form

Send the completed form along with a copy of your photo ID to:

Lima Memorial Health System
Attn: Medical Records
1001 Bellefontaine Ave.
Lima, OH 45804
Fax: (419) 226-5061
Phone: (419) 226-5025

If you are planning to pick up the records, "Information Released/Exchanged To:" may be left blank.

Please note:

  • There may be a charge for copies of records.
  • Processing record requests may take at least 48 hours.

You will need Adobe® Acrobat® Reader to view PDF documents. Download a free copy from the Adobe Web site.