If you are interested in obtaining a copy of your medical record(s), please print and complete the Authorization For Release of Protected Health Information. (PDF - 238 KB)
Upon completion, you may fax, mail, or personally deliver your Authorization to the Health Information Management (HIM) Department at Fawcett Memorial Hospital.
In order to verify your identification and validate your authorization, we require that you include a legible copy of a valid photo I.D. (e.g., driver's license, military I.D. or state I.D.), and a telephone number. Per Florida statute, there is a charge for providing the copies of the complete chart. This charge is $1.00 per page. There is a charge of 25¢ per page to pick up copies of your records.
Please allow 5 - 7 business days for us to process your request.
Fawcett Memorial Hospital
Health Information Management (HIM) Department
21298 Olean Blvd
Port Charlotte, FL 33952
Tel: (941) 629-1181 ext 6237
Fax: (941) 627-6141
Monday - Friday | 9am - 4pm
For further information or assistance with the Authorization form, please call (941) 204-0030.