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

Download our fillable PDF authorization form and complete. (New forms will need to be used here)

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.