Medical Records Request

This form serves as a means for employees to request copies of their medical records and/or health information on file with the University.

Requestor's Name

Requestor's Title

Requestor's Address

Requestor's City

Requestor's State

Requestor's Zip Code

Requestor's Email

Requestor's Phone Number

Requestor's Date of Birth (mm/dd/yyyy)

Requestor's Last 4 Digits of Social Security Number

Specific types of records requested

Dates of employment for which you need records

Where would you like the medical records emailed?

I authorize Saint Louis University to release the requested medical records on file with the University to the email address provided.

Confirmation

Other Fields

Your name

Your email address

Verification Code