Request for Access to Protected Health Information

To Request Your or Your Child's Records

Please complete 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.

To Request An Individuals Records

Third parties, please complete 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 314-996-4410
You may return it to: 
Missouri Baptist Medical Center
Attn: Health Information Management
3015 N. Ballas Rd.
St. Louis, MO 63131

Please note that a fee may apply.

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 314-996-5155 or 314-996- 5383 between 8 a.m. and 4:30 p.m. Monday through Friday.




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