Medical Records

At Memorial Hospital in Belleville, we want to have all the necessary resources to help manage your health care.

For Personal Use or Sending to Others

Please complete the Request For Access To Protected Health Information By Individual Patients to have a copy of your medical records sent to you or to someone other than yourself.

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

Request for Access to Protected Health Information form

Third Party Request:

Third parties, please complete the Request for Access to Protected Health Information by Individual Patients Form to request a copy of an individual’s medical records. 

Note: The individual whose records are being requested must sign this authorization.

Request for Access to Protected Health Information by Individual Patients form

Submission Instructions:

Mail a request to the following address

Mail:

Memorial Hospital
Health Information Management
 
ATTN: Release of Information
 
4500 Memorial Drive, Belleville, IL 62226

Fax: Send completed forms to 618-257-5319

Additional Services

The Patient portal provides secure online access to health records. The portal includes Non-Discrimination Information that offers free aids for disabilities and language services to enhance communication, while privacy practices outline your patient rights and how your health information will be used.

For questions about medical records, call: 618-257-5300

Contact Information

Phone

• General Inquiries: 618-257-5300
• Fax for Authorization Forms: 618-257-5319

Medical Records Department

Hours of operation: Monday–Friday: 8:00 a.m.–4:30 p.m.

Additional Information

• Records are handled securely and in compliance with HIPAA regulations.
• Assistance is available for completing forms or addressing questions about your request.
• Patient privacy