Request Medical Records & Authorization Forms
Patients and legal guardians complete the Request to Access PHI Form and mail to the address above.
Send completed form to:
400 N. Caldwell
Staunton, IL 62088
Authorization to Treat Minor
This form can be filled out by parents and guardians of children to give a designated person such as grandparents, babysitters, teachers, etc. authorization to have their child treated for medical emergencies.
For more information, please call 618-635-4257. Fax 618-635-4354