Please print, complete, sign and date the Release of Information Authorization form:
Release of Information Authorization Form
A copy of your Driver’s License/ State Photo I.D. is also required.
You may either fax or bring in your completed and signed ROI Authorization form AND a copy of your Driver’s License/ State Photo I.D. to:
Fax: (330) 926-9432
Address:
Center for Pain Medicine
Western Reserve Hospital
1900 23rd Street
Cuyahoga Falls, OH 44223
You will receive a phone call when your request is complete.
a. Please be aware that a charge may apply to your request; we will inform you of this when we call you.
b. If you are having someone else pick up your records for you, please either include that information on your signed authorization or have your representative bring in a signed/dated note from you authorizing them to retrieve your records. They must also bring their photo ID.
You will receive a phone call if your authorization is unsigned or otherwise incomplete and/or if we are unable to complete your request.
If you have any questions, please call us at (330) 971-7246