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Request a Copy

You can request a copy of your Miami Valley Hospital (MVH) medical record to be sent to you or a designated recipient. A processing fee may be required.

Written Authorization Required

The Authorization for Release of Medical Information/Patient Access Form is your authorization to copy your MVH medical record, or parts of your record, and forward it to another person or organization. Your original signature is checked against our records to validate the authenticity of your request.
 
You can get this form one of three ways:

  • Download it. To open the form you’ll need Adobe® Acrobat Reader®, which you can download for freeOff Site Icon
  • Call the Medical Records/Health Information Management Services Department to request that the form be mailed to you: 937-208-2806.
  • Stop by the Medical Records/Health Information Management Services Department during regular business hours, 8:00 a.m. to 9:00 p.m. (You will need to show a valid form of personal identification)

Submitting an Authorization

Submit a signed copy of the authorization form by mail, fax, or in person.

Mail

Miami Valley Hospital
ATTN: Health Information Management Services
One Wyoming Street
Dayton, OH 45409-2793

Fax

937-208-2961  

In person

The Medical Records/Health Information Management Services Department is located on the first floor near Registration.
Hours are from 8:00 a.m. to 9:00 p.m.

Please allow up to 10 working days for your request to be processed. If you come to the Medical Records/Health Information Management Services Department to pick up your copy, please bring a photo ID.

Who Can Request a Copy?

The following people are authorized to sign for the release of medical records:

  • Patient (not the spouse)
  • Parent (with some exceptions)
  • Legal guardian (proof of guardianship document must be provided)
  • Power of attorney if the patient is unable to sign (legal documentation must be provided and must specify access to medical information)
  • Representative of the estate for a deceased patient (legal documentation must be provided, including a copy of the death certificate)
  • For a deceased patient, contact the Medical Records/Health Information Management Services Department during regular business hours of 8:30 am to 9:00 pm

Processing Fees

Healthport is a contracted copy service at MVH in Medical Records/Health Information Management Services. The phone number is (937) 208-3983. Healthport’s standard fees for copying medical records are:

Patient Access Fees

1 to 10 pages

$1.22 per page

11 to 50 pages

$ .63 per page

51 pages or more

$ .26 per page

Note: Prices do not include tax.

There is no charge if records are sent directly to your physician.

Processing time for copies of medical records is 7 to 10 working days after receipt of a valid authorization and final completion of the medical record by all physicians involved.

There is no charge for copying and mailing a medical record if it is being sent to another health care provider or facility or if it is being used for a social security disability claim. Medical record requests for social security disability claims must be accompanied by a supporting letter from the Office of Social Security. There is also no charge for record requests related to social security disability claims.

DISCLAIMER: Miami Valley Hospital does not have any control over the content of third-party websites and neither endorses nor accepts any responsibility for the content, products, and services on or sold on these websites. The Off Site Icon symbol indicates a third-party website.