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Medical Records Requests

To obtain copies of your medical record, you will need to complete the “Authorization to Release or Request Information” form.

Release of Information Form (English and Spanish)

Sample Form - English

Complete the authorization indicating what records you are requesting. Instructions are attached to help you complete the authorization form.

For Behavioral Health records: Minors between the ages of 12 and 17 will require the signature of the minor and parent/guardian. Information for minors under the age of 12, only requires the parent/guardian signature.

Please note that verbal authorizations CANNOT be accepted.

Please fill out the form in its entirety. Non-compliant forms (missing required information) will be returned and will delay the process of receiving a copy of your medical records.

Valid releases may be faxed to 630-510-5485, mailed to 111 N. County Farm Road, Wheaton, IL 60187 or dropped off at any of our Public Health Center Locations. Hours are Monday thru Friday 8:00am to 4:30pm. Questions should be directed to our Medical Records Department at 630-221-7652.

Fees

There is no charge for information sent directly to another physician or medical provider. Client’s requesting their own information will be given information the first time for no charge. Charges may be assessed for each additional request.

Delivery

To protect your privacy and security, medical records will not be emailed. Records requested can be faxed, mailed or picked up at one of the Public Health Centers. Hours are Monday thru Friday 8:00am to 4:30pm.

Processing Time

Please allow up to 30 days to process your request