To request a copy of your records to be sent to another party, you will need to complete the

 

Unison Authorization for Disclosure Form 

Print and MAIL the completed form to:
Unison Health
1425 Starr Ave
Toledo, Oh 43605

OR

FAX form to:
Unison Health
419-936-7650

If you have questions about the form or to speak with someone regarding your request, please call our Medical Records Department at 419-936-7504. You can also come in to any of our locations and we will assist you in completing the form.

Please note
If you would like a copy of your medical records, there is a charge for this service. These fees are in accordance with HIPAA and Ohio State Law and are provided below:
$16.84 Search Flat rate
$2.74 per page for pages 1-10
.57 per page for pages 11-50
.23 per page for pages 51 and higher
Please contact our Medical Records office if you would like more information on how to receive a copy of your medical records.