Request Medical Records & Authorization Forms
Form: Request Medical Records
Send completed form to:
Health Information Management Department
6800 State Route 162
Maryville, Illinois 62062
Patients and legal guardians complete the Request to Access PHI Form
and mail to the address above. Instructions on completing the form can be found here.
Form: Authorization to Treat Minor
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.
If you are a Healthcare Provider: 618-391-6100618-391-6100
If you are the Patient: 618-391-6102618-391-6102