Authorization for Release of Health Information

The Authorization for Release of Health Information form is used by patients to release protected health information in cases that they wish to do so. This formal release is required by federal and state laws. In cases that you wish to share your health information, your authorization allows for the release of your information to the person or organization of your choice.

If you have questions, please call (307) 634-2273.

Form Information & Instructions


Please mail or fax the completed form to us:

ATTN: Medical Records
214 E 23rd Street
Cheyenne, WY 82001

(307) 432-3108