Authorization for Release of Health Information

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.

MyChart

If 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
2600 East 18th 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