Request for medical records

How do I request a copy of my/my child's health information?

To request a copy of your/your child's health information, complete an Authorization for Release of Patient Health Information form, and submit it to the Health Information Management Department.

You may submit the request in person from 8 a.m. to 4:30 p.m., or by mail to:

Children's Memorial Hospital
Health Information Management
2300 Children's Plaza, Box 11
Chicago, IL 60614-3363
Attn: Release of Information

You may also fax the request to:
773.880.3428
Attn: Release of Information

If you/your child are hospitalized, you may submit the form at the Health Information Management Department, located in the basement, upon discharge from the hospital.

Who is authorized to sign for release of my health information?

The following people are authorized to sign for release of health information:

  • The patient, if 18 years of age or over (not a patient's spouse or a parent of a patient over 18)
  • The parent or legal guardian, if the patient is younger than 18 years of age, with the exception noted here:
    The patient if 12 or over requesting a mental health record release, or records containing HIV/AIDS, drug and alcohol, sexually transmitted disease, pregnancy and/or birth control information (According to state law, a child 12 or over must authorize release of this highly confidential information.)
  • A guardian, if the patient is legally judged incompetent
  • Emancipated minor (the minor is legally married, is a parent, is pregnant, or has been legally emancipated by the court)

How much does it cost to obtain a copy of my health information?

  • There is no charge for releasing copies of health information directly to other healthcare providers. (The records must be sent directly to the healthcare providers' address.)
  • Patients will be charged a fee for copies of their health information.
  • To reduce the cost, patients should consider requesting specific information rather than a complete record, or having another party request on their behalf (e.g. insurance company).
  • The fee for patients to access copies of their health information is postage plus the following charges:

Number of copies

Medical Records

Microfilm/Electronic Documents

Pages 1-25

$0.89 per page

$1.49 per page

Pages 26-50

$0.59 per page

$1.49 per page

Pages 51 and up

$0.30 per page

$1.49 per page

When will I receive a copy of my medical record?

Copies are processed within 10 business days from the date the request is received by Children's Memorial Hospital. Requestors will be notified if the request cannot be processed within that timeframe.

If you have any questions, please contact the Health Information Management Department at 773.880.4404.

Guidelines for completing the form

Patient information – Please print the following:

  • Patient's full name
  • Patient's date of birth
  • Address
  • City/State/ZIP
  • Telephone number

Recipient

  • Leave the “From” area blank unless you are requesting records from another hospital or physician to be sent to Children's Memorial Hospital.
  • Print the name/institution and address to whom you wish your records to be sent. (There is no charge for releasing copies of health information directly to other healthcare providers.)

Date(s) requested

  • Specify the date(s) of treatment for which you are requesting records. Documents will be copied for the dates of treatment you specify.

Type of information requested

  • Select the category or categories of information you specifically want copied.
  • If the record contains any of the highly confidential items listed, they must be checked off specifically in order to be released.
  • To reduce your cost, you should consider requesting specific information rather than the complete record (check the “Abstract” box to do this).

Highly confidential items

If you would like any of the highly confidential items listed to be included in the release of your records, they must be specifically checked off. Please note the signature requirements listed.

Purpose

Select or describe the purpose for releasing the information.

Authorization expiration

Specify the date on which the authorization will expire. If not otherwise specified, it will expire within 30 days of the date of signature, the exception being mental health releases which expire in one year from the date of signature.

Signature

If you are the authorized requestor, please sign and date the authorization. Information will not be released without proper signatures.

Supporting documentation

If your signature cannot be validated, you may be asked to provide supporting documentation that proves your authority to sign the authorization on the behalf of the patient.

If you are requesting Mental Health Records, please have your signature witnessed.