Request Your Records
Request your Records
To access, review or obtain a copy of your medical records, call 330-253-3100 and press option 4, or email email@example.com. Should you choose to communicate with PPBH via email, we do NOT respond to records requests directly by email. Because of our respect for your privacy, records will be sent through U.S. Mail, or you can make arrangements to pick up your records in person.
Patient confidentiality is a cornerstone of what we do, and we take it very seriously. For that reason, it can take some time to release a medical record, as we need to assure everything is in order.
To begin the process of requesting your record, you (or in certain cases your authorized representative) must complete and sign a form authorizing the release of your information. This form needs to be completed and must indicate the specific contents of the record you wish to access, review or obtain, as well as the date(s) of service.
Click below to open a PDF of our release of information form. You can print it, fill it out and return it to us.
Note: the recipient for release of Substance Use Disorder (SUD) records must be an individual, not an entity/agency.Release of Information Form (Behavioral Health) (PDF)
There is no charge to access or review your medical record. There is a nominal charge to obtain a copy of your medical record. This charge covers the costs of preparing, copying, and mailing the record to you. We will inform you of the cost before preparing your records for release. If you agree to the cost, payment is due before your record is prepared.
We will notify you (or your authorized representative) in writing within 30 days of your request (60 days if the record is not maintained on-site – this happens as some older records are placed in secure storage), if and when the record will be available, and details on how to follow up.