Request Medical Records

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


Attorneys and third party requestors complete the HIPAA Authorization Form and mail to the address above.

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: 618-391-6100 
If you are the Patient: 618-391-6102