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How to obtain an Authorization for Release of Information Form

If you would like to obtain this form, you may call 244-3700 and request the form be mailed/faxed to you or you may stop by the MVTHS Main Office to pick one up. You can also click on the link below to bring up a copy of the Authorization for Release of Information Form that you can print, complete, and return.

Authorization for Release of Information Form

Complete the form and return one of the following ways:

USPS
Main Office
320 South 7th Street
Mt. Vernon, IL 62864

FAX
618.244.8047

SCAN/EMAIL
pramirez@roe25.com

HAND DELIVER
Main Office (A201)

Your Authorization for Release of Information Form will be processed in the order in which it was received. Please allow three (3) to five (5) days after your form has been submitted for your records/information to be sent via USPS or to obtain it in person.