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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

Instructions:
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.

Instructions:
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