Please complete the form as follows:
- Fill in the name of the patient (please print), and their date of birth.
- Fill in the patient’s address, city, state, zip, and telephone number.
- Facility authorized to release my health information: Trumbull Regional Medical Center
- Fill in the physician, agency or individual authorized to receive this information.
- Fill in the physician, agency or individual’s address, city, state, zip, and telephone number.
- Mark the health information that may be used/disclosed by checking the box next to the specific health information. (i.e. x-ray report, discharge summary, etc.)
- Complete the date of service for the health information you are requesting to be released.
- Check the purpose why the health information is to be used/disclosed.
- The patient’s signature or authorized personal representative’s signature should appear on the signature line along with the date and time.
- If acting on behalf of the patient, your relationship should be listed. All authorized paperwork (POA, Guardianship, etc.) must be submitted along with the authorization.
- Witness’s signature should appear on the witness line.
- If you would like to receive an electronic copy of your records, please check mark the box at the bottom of the authorization “Electronic Copy Requested.”
Please submit ALL copies of the authorization. Your request will be processed as soon as possible. Copy charges must be prepaid prior to release of records through our third-party vendor MRO.
If you have any questions, please call 330-841-1907 or 330-841-9578. Our office hours are Monday through Friday 8 a.m. - 4:30 p.m.