Patient Form

Memorial Hospital
4500 Memorial Drive
Belleville, Illinois 62226-5399

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 is providing its Authorization Form on its Website 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.

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Patient Authorization To Disclose Protected Health Information Form (PDF Format)

 

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Notice Of Privacy Practices