Get Authorization Form Kettering Health Overview Patients and Visitors Medical Records Learn more about requesting a copy of your medical records. Get Authorization Form Protecting your confidential health information is important to us. Our Release of Information Department maintains your medical records, so it remains safe and available to you when you need it. Your medical record is a summary of the services you received during your hospital visit. It contains your Health history Lab tests Nursing notes Physical exams Prescribed medications Plans for further care We maintain a confidential medical record for each patient we treat, and, as a patient, you have the right to view that record. Requesting a Copy To request a copy of your medical record, complete and submit this authorization form [PDF]. You will also need to include a copy of your photo ID. To request your medical records to be emailed, complete the form above as well as this email consent form [PDF]. Please allow for ten business days to process your request. Information located off-site or authorization forms that are improperly filled out take longer to process. If your request requires a fee, you will be notified of the fee before the record is sent. MyChart Access You can securely access portions of your medical record online through MyChart. To do this, you must activate your Kettering Health MyChart account. To get access to a family member’s MyChart account, please print and complete this MyChart Proxy Access Consent Form. Mail or fax your completed form to the Release of Information Department. Kettering Health Information Systems will contact you when your access is granted. Contact Us Mail complete forms to the following: Kettering Health Release of Information Department 1 Prestige Place, Suite 540 Miamisburg, OH 45342 Office: (937) 762-1200 Fax: (937) 522-8444 Email: gro.htlaehgnirettek@noitamrofnifoesaeler Who Can Access My Medical Record? Your medical record is a confidential legal document and can be requested only by the following: You, the patient (not your spouse) Your parent if you are younger than 18. Your legal guardian (with proof of guardianship document) Your power of attorney if you are unable to sign (with legal documentation provided). Requests for medical records of a deceased person require the following legal documentation: Court appointed Executor of Estate, Death Certificate, and a signed consent to request the records. Court appointed Affidavit of Kinship, Death Certificate, and signed consent to request the records. *Please note, after a patient’s death, The Medical Power of Attorney (POA) is ceased and no longer valid. Cost to Request There is no cost when the request for your medical record is made by Your physician (request by calling the Kettering Health Release of Information Department at (937) 752-2200 or by faxing a request on office letterhead to (937) 522-8444) Ohio Department of Job and Family Services Social Security disabilities benefits (request must include documentation that verifies the filing of the claim) There is a prepaid cost when your medical record is requested by Attorneys Insurance companies Patients and their families The cost for a paper copy includes a flat fee of $18.50 plus the cost of postage. An electronic copy requires a flat fee of $6.50. Obtaining Other Records Your medical record does not contain birth certificates, death certificates, or imaging films (such as X-rays). To request a copy of a birth or death certificate, contact the following: Montgomery County Vital Statistics (937) 469-3117 To obtain copies of imaging films, please contact the appropriate radiology location. Stories worth sharing View all Stories Health Tips Grief During the Holidays: Use the 3 Cs to Help You Heal News Daniel Tryon Named President of Soin Medical Center and Greene Memorial Hospital Find a Location We’ll help you locate a Kettering Health location near you. Our Locations Find a Doctor We’ll help you locate a Kettering Health provider near you. Find a Doctor Kettering Health is committed to transforming the healthcare experience for every person in our community. Get Authorization Form COVID-19 Vaccine Information: Click here for the latest information on Coronavirus (COVID-19), vaccines, and visitor restrictions. 3535 Southern Blvd Kettering, OH 45429 Facebook Twitter Instagram LinkedIn YouTube Quick Links Resources About Us Employees and Partners Copyright © 2021 Kettering Health. All Rights Reserved. Patient Rights & Website Policies Notice of Privacy Practices