If only a portion of the record is required, please specify below:
Identify the date of service or date ranges requested including month and year
The authorization must be signed and dated and may be revoked by notifying Hospital's Health Information Department in writing
at any time except to the extent action has been taken prior to revocation. This consent will expire 60 days after the date beside my
signature or sooner by my choice, in which case this consent will expire on this date or event: 12/23/2021. Such expiration date or event has not occurred.
By Selecting "Continued Medical Care" or "Insurance Purposes (Short/Long Term Disability and FMLA)" option, the records can be faxed.
Would you like to change the "Delivery Method" to "Fax"?
Unable to verify your MyChart account.
You can click the "Cancel" button to continue without authentication, which will default
the delivery method to "Mail-USPS". To set up an account, or verify your current acount status click:
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