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Request Medical Records & Authorization Forms PDF Print E-mail

Form: Request Medical Records

Cost: Nominal fee based on the number of pages.

Send completed form to:
Health Information Management Department
Suite 175
6800 State Route 162
Maryville, Illinois  62062

Download and complete the Authorization for Release of Medical Information Form (PDF format) and mail to the address above.

Form: Authorization to Treat Minor

The following form can be filled out by parents and guardians of children to give a designated person such as grandparents, babysitters, teachers, etc. authorization to have their child treated for medical emergencies.

Download and complete the Authorization to Treat minor form and provide copy to your designated person.

Download PDF Form Here

Phone Numbers:
If you are a Healthcare Provider:  618-391-6100
If you are the Patient:  618-391-6102