Medical Authorization Form

To request a copy of your Medical Record from Providence Medical Center, print off the linked form here, and mail or fax that form along with a copy of your official state ID to 913-596-4461.

If you have questions, feel free to call us at 913-596-4162, Monday through Friday, 8 a.m. to 4:30 p.m.

Click here to obtain our Authorization For Release of Information Form.