To request client medical records from OhioGuidestone, the following form must be completed and signed by the client or legal guardian, if the client is a minor.
- Authorization for Release of Information – English
- Consentimiento para Compartir Información – Spanish
Please complete ALL fields on the form before signing and dating it. Incomplete fields may result in a delay to fulfilling the request for records. Any records that contain alcohol/drug use diagnosis, referral or treatment are protected by 42 Code of Federal Regulation Part 2 and require specific permission from the client to be released.
- Client name and date of birth help us to select the correct records
- Recipient information should include the preferred method to receive the information whether fax or mail. Records can be provided via email but will be encrypted and require password protection.
- Type of information to be released should be checked or specified. No alcohol/drug diagnosis, referral, or treatment information will be disclosed without specifically identifying it as permitted to release.
- Indicate the purpose of the disclosure.
The form may be returned to OhioGuidestone via
- fax at 440-398-8135 or
- email to firstname.lastname@example.org
OhioGuidestone will respond to the request for medical records within 30 days of receiving the request.