How Does It Work?

Simply download the PDF of the request form below, fill it out, sign it, and bring it in to the office. You can either have us send your records to another practice, or have another practice send your records to us.

For records to be released by FPOG, we require the completed form with an “original” signature be mailed or delivered to our office. Faxed copies will not be accepted. You will need to provide a signed form to your former provider in order to have records transferred to our practice.

For records to be released to FPOG, please print out the form and turn it in to the practice from which the records are to be released. Make sure to find out from that practice their policies about facsimiled and original signatures.

Forms

Request that records be released...	...BY us: releasefrom.pdf
	...TO us: releaseto.pdf

Adobe® Reader® is required to view these documents. 

Pricing Structure

Ohio Law HB331, effective 1/1/2005, allows medical providers to charge for copies of medical records. According to Ohio Law HB331, the following charges are required:

Paper Records:

• $2.50 per page for the first 10 pages
• 51¢ per page for pages 11-50
• 20¢ per page over 50
• Postage cost

Non-Paper Records:

• $1.70 per page
• Postage cost

The full text of the law can be read at the Ohio General Assembly website.