Patient Forms
We want to make accessing your healthcare information simple and stress-free. Use the downloadable forms below to authorize emergency care, as well as the release of medical records and test results. You can view, print and complete each form at your convenience.
Medical Emergency Release Form
Are you a parent or guardian to a minor child? This form authorizes emergency medical treatment for your child when you can’t be reached. It gives care teams the information they need to act quickly in urgent situations.
Authorization to Use or Disclose Health Information
Use this form to give us permission to share your health information with another provider, organization or individual of your choice.
Receiving Copies of Medical Test Results
The Fisher-Titus Health Information Management (HIM) Department can help you access your test results, but there are some important things to know:
What HIM Cannot Do
HIM staff cannot release test results over the phone, even to the patient.
What HIM Can Help With
- Provide copies of results to you or your authorized representative
- Release results to designated providers or organizations with written authorization
How to Request Your Results
Fisher-Titus recommends starting with the Patient Portal for the fastest and easiest access.
- Patient Portal (recommended and no authorization required): Log in to the Fisher-Titus Patient Portal to view and download your medical records securely online.
- Authorization Form: or instances other than continuity of care where medical records are needed, Fisher-Titus will provide one free copy of medical records. Anything after the one free copy, Fisher-Titus follows the fee schedule provided by the state of Ohio for the cost of providing copies. One fee schedule is for providing copies for patients, and one is for providing copies to others.
- Submit electronically using Adobe Fill & Sign and email to recordsrequest@ftmc.com.
- A valid photo ID is required before results can be released.
- Representatives (e.g., parents, guardians, conservators) must provide legal proof of their role. Both custodial and non-custodial parents may authorize and access records for minor children.
- Call Our Office: If you cannot use the options above, call 419-660-2702, Monday–Friday, 7:30 a.m. to 4:00 p.m.