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Request Medical Records

Request for Access to Protected Health Information

Please complete this this form to have a copy of your medical records sent to you or to someone other than yourself. Note: Parents and guardians, please use this form for your patients.

Authorization for Release of Information 

Third parties, please complete this this form to request a copy of an individual’s medical records. Note: The individual whose records are being requested must sign this authorization.

Once you complete the form(s), you may fax it to 573.760.8024, or you may return to: 

Parkland Health Center
Attention: Health Information Management
1101 West Liberty Street
Farmington, Missouri  63640

These documents are in PDF format and require Adobe Acrobat Reader. If you don’t have this software, go to Adobe for a free download. If you have any questions, call 573.760.8015 between 8 a.m. and 4:30 p.m. Monday through Friday. Please note that a fee may apply.

Find a doctor or make an appointment:
573.431.3338 OR CALL TOLL-FREE 800.392.0936
General Information:
573.756.6451 OR CALL TOLL-FREE 800.734.3944
Copyright © 1997-2017. BJC HealthCare. All Rights Reserved.
Parkland Health Center -- Bonne Terre
7245 Raider Road | Bonne Terre, Missouri 63628
phone -- 573.358.1400
Parkland Health Center -- Farmington
1101 West Liberty Street | Farmington, Missouri 63640
phone -- 573.756.6451