If you are interested in obtaining a copy of your medical record(s), please print and complete
Authorization For Release of Protected Health Information − English (PDF - 52 KB).
Authorization For Release of Protected Health Information − Spanish (PDF - 334 KB).
Upon completion, please mail or personally deliver your Authorization to the Health Information Management (HIM) Department at Edward White Hospital.
In order to verify your identification and validate your authorization, we require that you include a legible copy of a valid photo I.D. (e.g., driver's license, military I.D. or state I.D.), and a telephone number. Per Florida statute, there may be a charge for providing the copy. Please allow 5-7 business days for us to process your request.
Edward White Hospital
Health Information Management (HIM) Department
2323 9th Avenue North
St. Petersburg, FL 33713
Tel: (727) 323-1111
Fax: (727) 328-6147
8 a.m. to 4 p.m. Monday through Friday
For further information or assistance with the Authorization form, please call (727) 328-6144.