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. If a copy of the abstract (ER, H&P, OR, D/C Summary, Labs, X-rays, EKG) is needed this will be provided for free with correct authorization.
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 6240
Fax: (941) 627-6141
8 am to 5 pm Monday through Friday
For further information or assistance with the Authorization form, please call (941) 204-0030.