Request for Access to Protected Health Information

Please complete the Request for Medical Records from 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.

Request for Access to Protected Health Information

Authorization for Release of Information:

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

Release of Information Authorization form

Once you complete the form(s), you may fax it to 314-996-4410, or you may return to: 

Missouri Baptist Medical Center
Attn: Health Information Management
3015 N. Ballas Rd.
St. Louis, MO 63131

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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