By requesting this form for specific information you agree to abide by all state and federal laws, which Southeast Missouri Behavioral Health also observes. The information requested will not be granted unless this form is completed fully.

After completing the form, please mail the original signed form (no faxes or copies) to:
Southeast Missouri Behavioral Health
ATTN: Medical Records
P.O. Drawer 459
Farmington, MO 63640

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