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 | Authorization Form
Authorization Form for Use and Disclosure of Protected Health Information
(35.2 K) |
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Medical Records Services
Medical Records Services maintains all records of patients seen in the Student Health Center. Records are retained for 7 years after the last patient visit or 8 years after a patient reaches the age of 18, whichever is later.
With proper patient authorization, the patient may obtain a copy of his/her medical and/or immunization records for a nominal fee. Requests for information are completed upon receipt within 7-10 working days.
Because your medical information is confidential and requires high levels of security, an authorization form with your signature on it must be completed prior to processing. There may be charges associated with your request and payment must be made prior to your records release. Our cashier is located on the 1st floor of the Wilce Student Health Center. We accept cash, checks, VISA, MasterCard, Discover and Buck ID. Please make checks payable to The Ohio State University. Please see below for charges that may apply.
Directions for Completing the Authorization Form.
- Download the authorization form (35KB) and print it out on any printer. Please note that a new version of this form was implemented on January 2008. The form that was available on the web site prior to that date will no longer be accepted.
*The authorization form is only available in .pdf format, click here to get adobe acrobat reader.
- Complete the authorization form in its entirety. Be sure to sign and date the bottom of the form. If you have any questions on how to fill out the authorization form please call Medical Records Services at (614) 292-0118.
*If any portion of the form is incomplete, it will be returned to the requestor and cause delay in processing.
- Mail the authorization form to:
Medical Records Services
OSU Wilce Student Health Center
1875 Millikin Road
Columbus, OH 43210
Or fax the form to: 614-292-7042
Charges for Medical Records Services:
- For Physicians or Healthcare Facilities: No Charge
- For a personal copy: $8.00
- For a third party (not related to continuing care): $8.00
- For an Attorney (including subpoenas) and Insurance Companies (not related to SHS claim processing): $15.00 pulling fee
- 1 - 10 Pages: $1.00/per page
- 10 - 50 Pages: $0.50/per page
- 50+ Pages: $0.20/per page
- For Radiology & Dental films: (no charge when requested by a physician) $7.00/per film
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