1000 Health Center Drive
Mattoon, IL • VIEW LOCATIONS
(217) 258-2525

Health Information Privacy Policies and Forms

Following are links to our health information privacy notice and authorization to disclose protected health information forms. The are saved in a .pdf format and can be viewed and printed from your computer. There is a service charge to obtain your record, and a photo identification is required before your record is presented to you. These pages are designed for optimum print quality. Please be patient while they download.

Adobe Acrobat Reader is required to open this file and can be downloaded free.

Privacy Notice   English   |  Spanish
Authorization to Disclose Protected Health Information
Request for Amendment of Protected Health Information

If you have questions about these forms or their use, please call Medical Record Management at:
217-258-2536
217-258-2122
217-238-4323
217-258-2374

 
Fax number to send authorization to:
217-258-2144