Medical Forms

*View the 'Download' section for the AD-66 Authorization for Uses and Disclosures of Patient Information.

How do I obtain a copy
of my medical record?

For your protection, we require that you, your guardian or legal representative, submit a request for the record in person, in writing and complete an authorization form*. Please give your name, Social Security Number, and birthdate. The written request must indicate where to send the records and be signed and dated by the authorized requestor. It would also be helpful to give the date of service at Knox Community Hospital you are requesting.

Submit written requests to:

Health Information Management
Knox Community Hospital
1330 Coshocton Road
Mount Vernon, OH 43050

You may pick up your record in the Health Information Management office, located on the first floor of the main hospital building. Our hours are 8 am – 4:30 pm, Monday through Friday. Please bring a valid photo identification with you.

  • To pick up the medical record you will need to:
  • Show your photo identification
  • Provide signature verification
  • Pay any charges

Can someone else pick up my medical record for me?
Not without the proper authorization* from the patient, guardian, or legal representative.

What if someone besides myself needs a copy of my medical record?
Your medical information is private and confidential. In compliance with the federal government Health Insurance Portability and Accountability Act, Knox Community Hospital will not release records without proper authorization from you, your guardian or legal representative.*

I've changed physicians. Can I get copies of my hospital records sent to a different healthcare provider?
Yes. There is no charge for this service. You, your guardian or legal representative will need to mail or fax a written request or complete an AD-66 Authorization for Uses and Disclosure of Protected Health Information form* and submit it to Health Information Management to be processed. There is no charge to have medical record copies sent directly to a healthcare provider for your continued healthcare.