Request for Access to Patient’s Protected Health Information

To Request Your or Your Child’s Records:

Patients and legal guardians, please complete the Request for Access to Protected Health Information by Individual Patients form to request a copy of your medical records sent to you or another legal guardian or personal representative.

Note: Parents and legal guardians, please use this form for your children.

To Request An Individual Patient’s Records for a Third Party

Patients and Third Parties, please complete the Authorization for Release of Information form to request a copy of an individual’s medical records to be released to a third party individual or institution. Note: The individual patient whose records are being requested must sign this authorization.

Request for Records for 3rd Party

Completed Centerpointe Hospital forms may be returned in person, fax , by mail or email to:

 CenterPointe Hospital
4801 Weldon Spring Parkway
St. Charles, MO 63304

Fax: 636 477-2132
Phone: 636 720-1659