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Request a Copy

You can request a copy of your Upper Valley Medical Center (UVMC) medical record to be sent to you or a designated recipient. A processing fee may be required. Call (937) 440-4650(937) 440-4650 or (937) 440-4651(937) 440-4651 for details. There is no charge if records are sent directly to your physician.

Patient Access Fees from a chart or electronic recorded

Cost per page: $0.05

Written Authorization Required

The Authorization for Release of Medical Information/Patient Access Form (also available in Spanish) is your authorization to copy your UVMC medical record, or parts of your record, and forward it to another person or organization. Your original signature is checked against our records to validate the authenticity of your request.
You can get this form one of three ways:

  • Download it: Authorization for Release of Medical Information/Patient Access Form (also available in Spanish). To open the form you’ll need Adobe® Acrobat Reader®, which you can download for freeOff Site Icon.
  • Call the Medical Records/Health Information Management Services Department at (937) 440-4650(937) 440-4650 to request that the form be mailed to you.
  • Stop by the Medical Records/Health Information Management Services Department during regular business hours, 8:00 am to 5:00 pm. You will need to show a valid form of personal identification.

Submitting an Authorization

Submit a signed copy of the authorization form by mail, fax, or in person.


Upper Valley Medical Center
ATTN: Health Information Services
3130 N. County Rd. 25A
Troy, OH 45373


(937) 440-4385

In Person

The Medical Records/Health Information Management Services Department is located on the Lower Level.
Hours are from 8:00 am to 5:00 pm.

When coming to the Medical Records/Health Information Services Department to pick up your copies, you will need a photo ID.

Before a medical record can be copied, the chart must be completed by all physicians involved with the care.  After a valid authorization is obtain, allow up to 30 days to complete the request.

Who Can Request a Copy?

The following people are authorized to sign for the release of medical records:

  • Patient (not the spouse)
  • Parent (with some exceptions)
  • Legal guardian (proof of guardianship document must be provided)
  • Power of attorney if the patient is unable to sign (legal documentation must be provided and must specify access to medical information)
  • Representative of the estate for a deceased patient (legal documentation must be provided, including a copy of the death certificate)

Content Updated: June 8, 2018

DISCLAIMER:Upper Valley Medical Center does not have any control over the content of third-party websites and neither endorses nor accepts any responsibility for the content, products, and services on or sold on these websites. The Off Site Icon symbol indicates a third-party website.
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