Patient Forms

Release of Information

Please print and complete this information and send to: Health Information Management, Jackson-Madison County General Hospital, 620 Skyline Drive, Jackson, TN 38301.

For more information, please call 731-541-7800.

Authorization for Release of Protected Health Information form

HIPAA Acknowledgement

West Tennessee Healthcare (WTH) does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, national origin, age, religion, disability, Limited English Proficiency or sex, including discrimination based on gender identity, sexual orientation, sex stereotyping or pregnancy in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by WTH directly or through a contractor or any other entity with which WTH arranges to carry out its programs and activities.

For further information about this policy, contact Amy Garner (731) 541-9914.