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.
Authorization for Release of Information:
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, 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.