MyChart -

NOTE: For release of medical records from Ashtabula County Medical Center (ACMC), Cleveland Clinic Akron General (CCAG), Union Hospital, your request must be made directly to:

If requester is not the patient (i.e. legal guardian, power of attorney), a copy of legal paperwork must accompany the request. Click here to request health information for someone else

This authorization does not include permission to release outpatient Psychotherapy Notes. Release of Psychotherapy Notes requires a separate authorization. (Psychotherapy Notes are defined as notes that document private, joint, group, or family counseling sessions that are separated from the rest of a patient's medical records.) Click here to request Psychotherapy Notes

I, the undersigned, authorize Cleveland Clinic to release health information as indicated/described below. I understand and acknowledge that, unless indicated below, the requested health information may contain information regarding physical and mental illness, STI test or diagnosis, HIV test results or diagnosis, treatment of AIDS/AIDS-related conditions, and/or alcohol/drug abuse.

This authorization and consent will expire one year from the date of authorization written below, unless revoked by me (or my legal representative) through written notice presented to Health Information Management (see contact information below). Any revocation will not apply to information that has already been released in response to this authorization. I understand that treatment, payment, enrollment, or eligibility for benefits will not be based on whether or not I submit this authorization.

After my health information is released, my information may be re-disclosed by the recipient and may no longer be protected by law. There may be a charge for this release of medical information. There is no charge to send to a health care provider.

Patient Name (First, Middle, Last) *

Cleveland Clinic Medical Record #

Last 4 Digits Social Security # *

Date of Birth *

Phone *

Patient's Current Address

Street Address *

City *

State *

ZIP *

Release Information From (check all that apply) *:

Cleveland Clinic Ohio facilities

Cleveland Clinic Nevada facilities

Cleveland Clinic Akron Physician Offices (PPG)

Cleveland Clinic Florida

I do not authorize Cleveland Clinic Florida to release health information regarding:

Mental Illness

STI test results or diagnosis

HIV test results or diagnosis

Treatment of AIDS/AIDS related condition

Treatment related to alcohol/drug abuse

If Ohio facility(ies) please specify:

Release Information To:

Release to Patient AboveRelease to Recipient Below

Recipient (If other than patient above): *

Recipient Address: *

Recipient Phone #:

Recipient Fax #:

Recipient E-mail:

Select Delivery Option *

Visit or discharge date from:

to:

Other Comments:

Purpose for Disclosure ( e.g. continuing care, personal use, legal): *

I understand and agree that by clicking “SUBMIT REQUEST” below, I am electronically signing this form and an electronic signature has the same effect as my written signature.

Authorization to Disclose Health Information