Use this form to ask another office, hospital, or clinic to fax or send your medical records to Mark Akers M.D., Inc. Open it in Adobe Reader or your browser, type in the shaded boxes, then print or save.
This form is also included in the New Patient Packet.
Download Records Request (PDF)
Where to send records
Dr. Mark Akers, MD, Inc.
81 Ashwood Dr.
Tiffin, OH 44883
Fax: 419-447-8446
Phone: 419-447-8444
Instructions
- Fill in the other office’s name and fax number at the top.
- Print your name, sign, and add your date of birth.
- Have the other office fax records to 419-447-8446.
- Do not email completed forms. They contain protected health information.