Upload Third Party Authorization Form | OSF HealthCare

Please use the form below to submit your third-party authorization for releasing hospital medical records.

Note: the document must be filled out completely and handwritten signatures are required.

*indicates a required field.

First Name: *

Last Name: *

Phone: *
Please provide the best number to contact you.

Email: *

Which hospital are you requesting records from? *

Third-Party Authorization Form: *
Combined file sizes cannot exceed 15MB

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