Memorial Hospital

Patient Authorization Form

Patient Authorization Form

Protecting your health information

The Privacy Standards of the Health Insurance Portability and Accountability Act (HIPAA) include specific requirements for the content of an authorization for disclosure of protected health information.

To assure authorizations comply with HIPAA requirements, Memorial requires the patient to complete Memorial's Authorization Form when authorizing disclosure of protected health information to a third party for non-treatment related purposes. Memorial provides a Patient Authorization Form on its web site to give requestors easy access to this form. This form can be downloaded, completed by the patient, and then directed to the appropriate department at Memorial for processing.

Memorial Hospital

4500 Memorial Drive
Belleville, Illinois 62226
(618) 233-7750

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