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.