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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.-4:30 p.m. Monday through Friday. Please note that a fee may apply.

Parkland Health Center
Bonne Terre
7245 Raider Road
Bonne Terre, Missouri 63628
Parkland Health Center
Farmington
1101 West Liberty Street
Farmington, Missouri 63640
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