Request for Medical Records
Fairview Park Hospital is committed to protecting your privacy. All requests received are processed and released by CIOX, our Release of Information vendor.
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 - 177 KB) .
- Be sure to fill the form out completely, including signing and dating. Failure to do so will result in a delay in processing your request.
- In order to verify your identification and validate your authorization, CIOX will 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.
- Records that are requested by someone other than the patient (e.g., holder of a medical power of attorney, court appointed guardian), additional documentation may be requested for proof of your authority to act on behalf of the patient as required by state and federal law.
- Since our records are located off-site, you will not be provided the option to pick up your records in person at the hospital.
Upon completion, choose one of the following options:
Mail the form to:
Fairview Park Hospital
P.O. Box 1408
Dublin, GA 31040
Mail the form to:
P.O. Box 922788
Norcross, Ga. 30010
Fax the form to:
Requests are processed in order received. Please allow five to ten business days for processing. If you have not received a response to your request within 10 business days, please contact CIOX directly at (877) 403-8825.
There is no charge for records sent directly to your physician or healthcare facility for continuing care. There is a fee for copying medical records for all other requests. CIOX charges 25-cents per page, plus postage and tax. CIOX will send you an invoice directly from their office: CIOX, P.O. Box 922788, Norcross, GA 30010