You can request a copy of your health information by completing an Authorization form (PDF) and submitting it to the SMH Medical Records Department. You can fax the form to 501.776.6078 or email it to our HIM director.
Download authorization form
You must submit this form in person and have a picture I.D. available. There is no charge for releasing copies of health information to patients or directly to other healthcare providers.
Q. WHO IS AUTHORIZED TO SIGN FOR RELEASE OF MY HEALTH INFORMATION?
The following people are authorized to sign for release of your health information:
- The patient (Not the spouse)
- Power of attorney if the patient is unable to sign (Legal document must be provided.)
- Parent (if the patient is younger than age 18)
- Parent and minor if the patient is 12 to 17 years of age and receiving psychiatric, alcohol, or drug treatment services
- Legal guardian (Proof of guardianship document must be provided.)
- Representative of the estate for deceased patients (Copy of the death certificate and a copy of the representative of estate documents must be provided.)
Q. WHO DO I CONTACT IF I HAVE QUESTIONS?
If you have any questions, please contact the Medical Records Department at Saline Memorial Hospital at 501.776.6071.