Request Medical Records & Authorization Forms

Form: Request Medical Records


Send completed form to:

Health Information Management Department
Suite 175
6800 State Route 162
Maryville, Illinois  62062

Instructions:

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

This 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.


Phone Numbers:

If you are a Healthcare Provider:  618-391-6100618-391-6100
If you are the Patient:  618-391-6102618-391-6102