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 ready 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, present your indentification, 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/Day Surgery Center, please complete this form. All fields are required. You will receive a phone call when your records are ready for pick-up.

Under the provisions of HIPAA and under the Illinois Mental Health and Developmental Disabilities Confidentiality Act, authorization for use/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 privacy laws. Information is protected under Illinois Law and may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy laws. Illinois law prohibits re-disclosure of HIV, alcohol, drug abuse and genetic information by the recipient except as otherwise allowed by law. This authorization will automatically expire one year after the date of signing if no prior notice for revocation is received. All original films must be returned in 15 days. I have requested information be sent to the facility/person named herein and this it not be further disclosed or used for any purpose other than as stated in this authorization. Any person who discloses mental health records and communication without proper consent/authorization may be subject to civil liability or criminal penalty according to 740 IL CS 110.

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

• required information

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 do hereby authorize Northwest Community Hospital,
or Other to release to:
Agency/Facility/Person •

Address •

City •
 State
 Zip Code •

For the purpose(s) of: •

Records for the period (dates: mm/dd/yyyy) from •
to •

Release the following information:
Discharge Summary
Radiology Report(s)
Operative Report(s)
Discharge Medication List
History and Physical
 Pathology Report(s)
Itemized Billing Statement
Cardiology Report(s)
Social History
Films/CDs
 Emergency Record(s)
Consultation(s)
Progress Notes
PT/OT/Speech
Treatment Plan(s)
 Lab Report(s)
Psych Evaluation
Abstract
(Document Summarizing Health History and Pertinent Information)
Other records as specified:
Entire Medical Record (Except for Records Concerning Highly Confidential Information mentioned below)
I also authorize the release of the following (check all that apply):
Alcohol/Drug abuse diagnoses and treatment records
Mental Health records
 Records of HIV/Aids testing, diagnosis or treatment
Genetic testing

I acknowledge that I have the right to revoke the authorization. I understand that my revocation must be in writing. I also understand that my revocation will be valid except to the extent that the person(s) or organization(s) authorized to make the requested use/disclosure have taken action in reliance on this authorization or 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 I have the right to inspect and copy my information that will be used or discussed pursuant to this authorization.

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

Patient's Signature •

 Date
(mm/dd/yyyy)
Signature of Minor (12-17 inclusive) •
(mental health and emancipated minor)

 Date
(mm/dd/yyyy)
Parent/Guardian/Representative Signature

 Date
(mm/dd/yyyy)
Relationship to Patient

I attest to the identity of the above signature(s).

Applicable fees will be charged for patients and attorneys.

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Last Updated 02/07/2012