Third-Party Authorization Form
If you are a third party and have been authorized to request medical records, you will need to submit an authorization form along with your request.
Authorization Form
and complete.
Print the document and sign. Note: handwritten signatures are required.
Submit Form
To submit the authorization, please do one of the following:
- Upload signed document using our online form below
- Make sure to include "Attn: Medical Records" when addressing.
Note: the document must be filled out completely and handwritten signatures are required.
In the spirit of Christ and the example of Francis of Assisi, the Mission of »Ê¹Ú¶ÄÇò HealthCare is to serve persons with the greatest care and love in a community that celebrates the Gift of Life.