Medical Records Release Authorization
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Medical record consent
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- Medical Records Release Authorization (95 Kb PDF) This form must be completed if you wish to authorize others to view your medical information.
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 3rd floor of the Wilce Student Health Center. We accept cash, checks, VISA, MasterCard, Discover, American Express, and Buck ID. Please make checks payable to The Ohio State University.
Directions for Completing the Authorization Form.
- Download the Medical Records Release Authorization (PDF). This form can be completed online and then printed, or can be printed and completed by hand. (Please use black ink.)
- Complete the authorization form in its entirety using black ink. 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 Health Information 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:
Health Information Services
OSU Wilce Student Health Center
1875 Millikin Road
Columbus, OH 43210
Or fax the form to: (614) 292-7042