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Record Release Requests

Printable Forms

Electronic Submission Form

Medical, Dental or Behavioral Health Records Electronic Request Form


AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PHI)

Patient Birthday
Month
Day
Year
Action Requested
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Northeast Missouri Health Council
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Northeast Family Health

1506 Crown Drive       

Kirksville, MO  63501

Phone:  (660) 627-4493

After Hours: 1-844-820-9111

Hours:

Monday: 8 a.m. - 12 p.m. & 1 p.m. - 5 p.m.

Tues/Wed/Thurs: 7:30 a.m. - 5:30 p.m.

Fri: 7:30 a.m. - 5 p.m.

Northeast Pediatrics 

402 W. Jefferson Suite A

Kirksville, MO  63501

Phone:  (660) 627-2229

After Hours: 1-833-745-2217

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

OB/GYN Specialty Group 

402 W. Jefferson Suite B

Kirksville, MO 63501

Phone: (660) 665-3555

After Hours: 660-785-1750

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

Edina Family Health

104 E. Jackson

Edina, MO  63537

Phone: (660) 397-3517

After Hours: 1-844-820-9111

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

Northeast Dental 

402 W. Jefferson Suite C

Kirksville, MO  63501

Phone:  (660) 665-2741

After Hours: 1-866-292-7780

Hours: 7:45 a.m.-11:45 p.m. & 12:45 p.m.-4:45

Macon Family Health & Macon Dental

209 N. Missouri

Macon, MO  63552

Phone:  (660) 395-5045

After Hours: Medical: 1-844-820-9111

After Hours Dental: 1-866-292-7780

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

Memphis Community Health Center

118 Grand Ave.

Memphis, MO  63555

Phone:  (660) 465-7522

After Hours: 1-844-820-9111

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

Kahoka Dental 

22291 US Highway 136

Kahoka, MO  63445

Phone: (660) 727-1500

After Hours: 1-866-292-7780

Hours: M, T, W, F 7:00 a.m. - 12:00 p.m.

1:00 p.m. - 4:00 p.m.

Thursday: 7:00 a.m. - 11:00 a.m.

Northeast Family Health - Milan 

52334 S. Business Highway 5

Milan, MO  63556

Phone: (660) 265-1042

After Hours: 1-844-820-9111

Hours:

Mon - Thurs: 7:30 a.m.- 12 p.m. & 1 p.m. - 5:30 p.m. 

Friday: 7 a.m. - 3 p.m.

Northeast Behavioral Health 

1410 Crown Drive

Kirksville, MO 63501

Phone: (660) 627-3621

After Hours: 1-800-356-5395

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

Envision Wellness

1506 Crown Drive

Kirksville, MO  63501

Phone: (660) 627-4493,  Ext. 412

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

Kirksville Veterans Clinic

506 Rosewood Drive

Kirksville, MO 63501

Phone: (660) 627-8387

After Hours: 1-800-349-8262

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

Business Office

1416 Crown Drive

Kirksville, MO  63501

Phone: (660) 627-5757, Ext. 6

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

Administrative Offices 

1416 Crown Drive

Kirksville, MO  63501

Phone:  (660) 627-5757 

Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

National Quality Leader in Maternal & Child Health
2024 Health Center Quality Leader
2024 Access Enhancer
2024 Health Disparities Reducer
2024 Health Information Technology
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This health center is a Health Center Program grantee under 42 U.S.C 254b, and deemed Public Health Service employee under 42 U.S. C. 233(g)-(n)
The health center receives HHS funding as has Federal Public Health Services (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.
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