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:
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
Other Downloadable Forms: