St. Rita's Medical Center

Medical Record Request

730 West Market Street, Lima, Ohio 45801

You may request information by completing the form below or you may contact the Medical Record Department at 419-226-9328.

All fields are required.

Patient's Name

Contact Phone Number


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ext

Date of Birth


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Date of Visit


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Email Address

Last Four Digits of Patient's Social Security Number

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Are you the patient?

Yes No

Why are you requesting the information? Please check below all that apply.

Personal Use
Another Healthcare Provider
Attorney
Insurance
Other
If other, please explain:

What information are you requesting? Please check below all that apply.

Emergency Room Report
Radiology Report
Laboratory Results
Other
If other, please explain:

Would you like this information sent to another healthcare provider?

Yes No

Your results will be available for pick up in two business days, Monday through Friday at the Medical Records Department between the hours of 7:00 a.m. to 5:30 p.m. Medical Records is located on the first floor between Walgreens and Radiology. According to State Law, we reserve the right to charge for copies of records for certain requests, such as insurance companies, attorneys and personal use. Acceptable forms of payment include cash and checks.

You will need to bring a means of identifying yourself before we can release your medical records. The following are acceptable identification: