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
- Authorization For Release of Protected Health Information (En Espanol)
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 may be a charge for providing the copy. Charges are $0.25 per page, and will be billed upon receipt of 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
Fax: (855) 446-6008
Mon - Fri | 9:00am - 4:00pm
For further information or assistance with the Authorization form, please call 1-866-463-7272.