Information About Obtaining A Copy of Your Medical Record

Your  medical records are confidential.  If you would want a copy forwarded to you or to your new physician, you will need to complete an authorization to release these records.  Unfortunately, your medical records cannot be released without this signed authorization.  An authorization form follows.  You can print, complete and return the form to our office once you have selected a new physician. The office address is: 

Facial Surgery Center
1130 Congress Avenue 

Cincinnati, OH  45246  

There will be a reasonable copying/mailing fee based on Ohio law to cover the cost of duplication and postage.  Please allow at least 14 days to process your request.

Copying Fees

Pages 1-10     X  $3.02 per page

Pages 11-50   X  $  .63 per page

Pages 51+      X  $  .26 per page 

With respect to data resulting from an X-ray, MRI, or CAT scan, recorded on paper or film

                        X  $2.07 per page

Summary Letter by Dr. Moravec (optional)   $75

Postage Based on Weight of Envelope

*Above fees are established by the State of Ohio.

Authorization Form