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Authorization for Release of Information

Request Your Medical Records

As a patient at Clinch Memorial Hospital, it's your right to get copies of most medical records. If you've received care at Clinch Memorial Hospital or see a Clinch Memorial provider for ongoing care, you may access your medical records, by request, at any time.
To submit your application, please fax or email it to the contact information on the form, or email it to ksirmans@clinchmh.org or cmoseley@clinchmh.org. If you would prefer to submit your application online, download and fill out the PDF linked above. Sign and save your PDF, then attach to the form below:

    Attach Application