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.