New Patient Forms
When you arrive at your University of Toledo Physicians’ facility, please stop at the registration desk to check-in. When checking in with the registration specialist, please give your name, the physician’s name, and your appointment time with whom you have the appointment. Please have your insurance card and photo identification to expedite the check-in process.
Below, patients can find the new patient forms that need completed before, or the day of, the first appointment. You may attach a scan or a legible digital picture of the completed forms. If our patients prefer to print out their forms and bring them to their appointment, they can do so as well. Patients can download and complete the forms in an easy fillable format and email them to our Patient Access Center at PAC@utoledo.edu. All forms must be downloaded to be submitted.
Confidential Communications Request
The Health Insurance Portability and Accountability Act permits you to have the right to request that communications regarding Protected Health Information (PHI) be provided through specific means and designated persons.
Patient General Consent
UTP is dedicated to caring for each person with respect and dignity and considers the patient to be a partner who wants to understand and make informed decisions about their healthcare. UTP also believes the patient and their family (as desired) can participate if they know their rights and responsibilities.
Notice of Privacy Practices
The Notice of Privacy Practices provides information about how we may use and disclose protected health information about you and your privacy rights.
Patient Registration Questionnaire (1557)
UTP recognizes a number of gender/sexes; many insurance companies and legal entities, unfortunately, do not. Please be aware that the name and sex you have listed on your insurance must be used on documents pertaining to insurance, billing, and correspondence. If your name and preferred pronouns is/ are different from these, please let us know.
Release for Medical Records
A patient, or his/her legal representative, may inspect and/or obtain a copy of their medical records, or have copies of medical records sent to another facility. The University of Toledo Physician’s group requires a completed and signed Authorization for Release of Health Information form before releasing any documents to anyone, including the patient. In certain cases, a patient’s physician, psychologist or social worker may also be required to approve a request.
If you have questions about this process, please feel free to contact the Health Information Management department directly at (419) 383-4982.
To Request a Copy
Print and complete the Authorization for Disclosure of Health Information (Request Amendment) form. The form must be completed, dated, and hand signed. The form is fillable and can be completed electronically up to hand signature, which is required.
- If you are unsure which records to request
- For outpatient services: the last 2 years of outpatient office visits & available testing are the most relevant.
To submit your request once your form is completed:
Please bring the form to:
Any UTP registration area
Toledo, Ohio 43614
If you have any questions or need guidance regarding release of health information, please call (419) 383-4982.
Release of Information Charges
There is no charge to release records to a healthcare facility for continuing medical care, or for copies of immunizations.
Paper copies: $0.05 per page for supplies (paper and toner) plus postage, and $0.90 flat labor fee
Electronic delivery (email or CD): $6.50 flat fee plus tax for any number of pages
- If someone other than the patient is picking up records, they must have an original patient-signed authorization (noting this person is ok to pick up), and a photo ID.
- If you are requesting the medical records of someone else, you may be asked to provide additional documentation. This may include Guardianship, Healthcare Power of Attorney, etc. If the patient is deceased, we will require the Death Certificate, with documentation of the personal representative. This may be Executor, Last Will and Testament, etc.
- Please allow up to 7-10 business days for your request to be processed.