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Authorization for release of protected health information

Capital Region Medical Center recognizes the rights of our patients to release their health information.

To facilitate a request for copies of medical records to be released, we ask that you:

  • Print the  'Authorization for Release of Protected Health Information' form.
  • Fill in all the required information on the form.
  • Sign and date the Authorization (must be signed by the patient, unless the patient is a minor or the patient has a legal representative assigned).
  • Include your phone number on the Authorization form in case we need to contact you.
  • Return the form by fax to 573.632.5998 or by US mail to:
    Capital Region Medical Center 
    Medical Record Department
    P.O. Box 1128
    Jefferson City, MO 65102-1128
  • Payment of a fee may be required in some circumstances before the information can be released.

If you have any questions about this process, please contact our release of information specialists at 573.632.5650.

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Capital Region Medical Center
1125 Madison St.
Jefferson City, MO 65101
573.632.5000 | 573.632.5880 (fax)

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