Request Medical Records

You can request a copy of your health information by completing a request and authorization form:

Click here for Authorization for Release of Information Application

You can submit this form to Clinch Memorial Hospital by mail or in person.

• If you are submitting your request in person, please bring it to the Clinch Memorial Hospital main campus. You may do so Monday through Friday from 8:00 a.m. to 3:30 p.m.
• Or mail to CMH Medical Records Dept., Clinch Memorial Hospital, 1050 Valdosta Highway, Homerville, GA 31634
• Or fax to HIM: 912-470-2335
• (Forms are NOT accepted via email)

The following people are authorized to sign for release of health information:

• The patient, not the spouse
• Power of attorney if the patient is unable to sign; legal document must be provided CMH Authorization Release Request Form
• Parent, if the patient is younger than age 18
• Legal guardian; proof of guardianship document must be provided
• Representative of the estate of deceased patients. A copy of the death certificate and a copy of the representative of estate documents must be provided

If you have any questions, please contact CMH Medical Record Dept at 912-487-5211