Helpful information for you to know.
At Evanston Regional Hospital, we're here to help you heal—and to make certain your experience with us is as safe, restful and restorative as possible. Here are a few things you might want to know to make the most of your hospital stay. Click here for the patient information guide or click the image to the right.
Questions of care.
Did you know that as a patient, you have a specific set of rights? That our hospital accepts most major insurers (but that you should check our list to make sure yours is among them)? That we offer spiritual counseling and other services? Read on to find out more.
Release of Medical Information:
Download the Release of Medical Information form here.
Please fill out all highlighted sections, including:
- Patient’s Name, Date of Birth, Address and Phone Number
- Facility Authorized to Release Information to:
- Records Released to you - write in “SELF"
- Records Released to another Provider or Facility - please fill in the Providers name, address, phone and FAX number.
- Health Information to be disclosed - include all dates of service, what type of records you want released (labs, x-ray, complete, etc.), why you need the information (treatment, insurance, personal),
- The Yes/No question is an authorization to release any sensitive information. Typically this should be marked yes if you require all of your information to be released.
- Patient’s or Authorized Personal Representative’s Signature – please sign, date and time.
- Leave the Witness Signature line and everything below it blank.
You will also need to include a legible copy of your DRIVER’S LICENSE or your Official ID so we may verify your signature with your hospital record.
You can return the form to us by mail. We cannot accept the completed forms by email or FAX at this time due to security reasons. Our mailing address is 190 Arrowhead Drive, Evanston WY 82930
If you have any questions, please contact:
Jill Holmes
HIM, ROI Specialist
307-783-8134