NCH - Northwest Community Healthcare
 
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Your Records • Request Medical Records Online

For your convenience, Northwest Community Hospital provides this online tool for submitting an electronic form request for medical records. By submitting this online form to the Medical Records department in advance, your records will be readied for you and you will save time. Please note: To protect your privacy and your records, you will still be required to pick up your medical records in person and sign for them.

AUTHORIZATION FOR USE and/or DISCLOSURE OF INFORMATION

PLEASE READ: To request copies of your medical records from Northwest Community Hospital, please complete this form. All fields are required. You will receive a phone call when your records are ready for pickup.

Notice to receiving person/agency: Under the provisions of HIPAA, authorization for use and/or disclosure is voluntary. Individuals are not coerced into signing an authorization, but provide the information freely. Once information is received by the authorized organization or person, then it may be subject to re-disclosure by the recipient and may no longer be protected by federal pricacy laws. Illinois Law prohibits re-disclosure of HIV, alcohol, drug abuse, and genetic information by the recipient except as otherwise allowed by the law. This authorization will automatically expire 90 days after the date of signing if no prior noticed for revocation is received. All original films must be returned within 15 days.

I have read and agree to the terms of this agreement. Yes No

Title
Mr. Mrs. Ms.
Patient First Name Patient Last Name
Birthdate  
(mm/dd/yyyy)
Address
City State Zip Code
Phone
Email Address
 
I, , do hereby authorize Northwest Community Hospital and/or Day Surgery Center to release to:
Agency/Facility/Person
 
Address
City State Zip Code
The following information:
Complete Chart
Abstract (Documents Summarizing Health History & Pertinent Information)
Outpatient Services (Lab, X-ray, Cardiology)
Other - Specific Records or Films
Concerning the hospitalization of (date(s) of discharge/service):
For the purpose(s) of:

I acknowledge that I have the right to revoke the authorization. I understand that my revocation must be in writing and should be addressed to the Health Information Management Department at the address listed below, and must be witnessed in person by a person that can attest to my identity. I also understand that my revocation will be valid except to the extent that 1) the person(s) or organization(s) authorized to make the requested use/disclosure have taken action in reliance on this authorization or 2) if this authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest the claim under the policy or the policy itself.

I understand that the person(s) or organizations authorized to make the requested used and/or disclosure may not condition treatment, payment, enrollment or eligibility for benefits, on execution of this authorization. I understand that this authorization includes the releases of information related to HIV if applicable.

With my electronic signature below, I acknowledge and affirm the statements in this authorization form.

Patient's Signature
Date  
(mm/dd/yyyy)
Parent/Guardian/Representative Signature
Date  
(mm/dd/yyyy)
Relationship to Patient

Applicable fees will be charged for patients and attorneys.

Back To Top10/06/2009