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Request for Records

All requests for Medical Information must be made in writing to the Medical Records Department. Forms may be dropped off during office hours, mailed or faxed.

Please download the Authorization to Release Medical Information form below, print and complete. Forms must be signed by the patient, legal representative, or legal guardian.

Mail or deliver to:
Molokai General Hospital
Medical Records Department
PO Box 408
Kaunakakai, HI  96748

Ph: 808-553-3114
Fax 808-553-3164

If you have any questions, please call 808-553-3114 during regular business hours, Monday through Friday, 8:00 am to 4:30 pm, excluding observed holidays.

Duplication fees may apply and fees must be paid in advance. There is no charge for physicians and other health care facilities for direct patient care if medical records are sent directly to a physician or health care facility, and are requested by the physician or health care facility. If a patient requests that information be sent to a physician or health care facility at the direction of the health provider, verification will be made before any records are sent.


Additional Information

Medical Records Release Form (Print)

Medical Records Release Form (Writeable PDF)

Paul G. Stevens, MD Outpatient Clinic Medical Release Form (Print)