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

Print the document and sign. Note: handwritten signatures are required.

To submit the authorization, please do one of the following:

Upload signed document using our online form below
Mail to the appropriate hospital. Make sure to include "Attn: Medical Records" when addressing.

Note: the document must be filled out completely and handwritten signatures are required.