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              Evanston Regional Hospital
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                  Patient Resources

                  You're number one.

                  Patient Resources Topics

                  Patient Rights and Responsibilities

                  Your well-being is our top priority

                  At Evanston Regional Hospital, your safety and comfort in our facility and with our staff is very important. Here you'll find a few pages about our promise of privacy and patients' rights, as well as a chance for you to tell us about more about how we did on your last visit.


                  Read our guidelines on your privacy and rights:

                  Privacy Policy
                  Patient rights & responsibilities  

                  Release of Medical Information:

                  Download the Release of Medical Information form here.  

                  Please fill out all highlighted sections, including:

                  1. Patient’s Name, Date of Birth, Address and Phone Number
                  2. 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),
                  3. 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.
                  4. Patient’s or Authorized Personal Representative’s Signature – please sign, date and time.
                  5. 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


                  Other Downloadable Forms:

                  Advance Directive forms  
                  Patient Handbook  

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                  Rights and Protections Against Surprise Medical Bills  
                  Patient Rights and Responsibilities  
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                  190 Arrowhead Drive
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                  190 Arrowhead Drive , Evanston , WY 82930
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