Authorization for Release of Health Information
Beginning January 1, 2023
In-person requests for medical records and/or pick up of medical records will be at the West Campus ONLY (main hospital) located at 214 East 23rd Street. Medical Records will be available Monday-Friday, 8 a.m. to 4:30 p.m. This service will no longer be performed at the East Campus (2600 E 18th Street).
If you would like to receive a copy of your medical records or have medical records sent to another party, please complete an authorization for release of information.
If you want a copy for yourself, much of your medical information can be found immediately in your MyChart account.
MyChartIf you have questions, please call (307) 633-7925 option 1.
Authorization for Release of Healthcare Information
Authorization for Release of Healthcare Information (Spanish)
Please mail, fax or email the completed form to:
MAIL:
Cheyenne Regional Medical Center
HIM Department
214 East 23rd Street
Cheyenne, WY 82001
FAX:
307.432.3108
EMAIL:
CheyenneRegionalHIM@crmcwy.org
Authorization to Verbally Disclose Health Information to Family or Other
To grant family members or others the ability to speak to CRMC personnel or CRMG clinics about your medical information, upcoming appointments, or billing, you need to complete and submit the verbal disclosure authorization. This is for verbal information only; it does not include copies of records. You may mail, fax, or email it to the above locations.
Authorization Form
MyChart Proxy gives the ability for others to access an individual’s billing and health record on a single sign-in. Complete the designated form below and mail, fax, or email it to the above locations.
Adult to Adult is for those patients over the age of 18 that would like to grant access to another person over the age of 18
MyChart Proxy Adult to Adult
For a parent or legal guardian to have access to a patient who is under 18 and not emancipated.
MyChart Proxy Adult to Child
Adult to Adult is for those patients over the age of 18 that would like to grant access to another person over the age of 18
MyChart Proxy Adult to Adult (Espanol)
For a parent or legal guardian to have access to a patient who is under 18 and not emancipated.
MyChart Proxy Adult to Child (Espanol)