Brenda Nielsen, Insurance Agent

Senior Benefit Services

Fax: (573) 443-4545

Phone: (417) 859-3285

If the records are being requested for a spouse, child that is above the Age of Medical Consent or other individual, they will be mailed directly to the patient.

I understand that if the Facility grants access to records, they will provide the requested records within thirty (30) days. Also, I understand there may be a cost-based fee charged to process this request and the Facility will contact me prior to continuing action on this request for my acceptance of the fee amount (if any).If the facility needs additional time, then the Facility’s Privacy Officer will notify me with the reason.

When completed, please return to Rogersville Pharmacy

Or Mail To:

Rogersville Pharmacy

317 S Main St

Rogersville MO65742