Name: | DOB: | MRN: | PCP:

Authorization to Disclose Health Information

This electronic form may be used by patients requesting their health information. If the person completing the request for health information is not the patient (e.g., court appointed guardian or durable power of attorney for health care), then you must use the following form for your request. Click here to request health information for someone else.

NOTE: For release of medical records from Ashtabula County Medical Center (ACMC), Cleveland Clinic Akron General (CCAG), Union Hospital, and Cleveland Clinic Weston, FL, your request must be made via the corresponding linked form below.

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 patient named below, authorize Cleveland Clinic to release health information as indicated/described below. I understand and acknowledge that the requested health information may contain information regarding physical and mental illness, 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's Current Address
Release Information From (check all that apply) *:
If you selected Cleveland Ohio facilities above, please specify the sites from which you are requesting health information:
Release Information To:
Information Requested: *

  Cleveland Clinic Contact Information:

  Health Information Management / Medical Record Department

  Health Data Services Ab7

  9500 Euclid Avenue, Cleveland, OH 44195

  Phone: 1-216-444-5580     Fax: 1-216-587-8043