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Your Records • Request Mental Health/Developmental Disability 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 and under the Illinois Mental Health and Developmental Disabilities Confidentiality Act, authorization for use and/or disclosure is voluntary. 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 only if permission for the re-disclosure is obtained, This authorization will be valid for 180 days after the date of signing and limited to only that information I am requesting below to be sent to the facility person named herein and that 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 ILCS et seq.

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

Title
Mr. Mrs. Ms.
Patient First Name Patient Last Name
Birthdate  
(dd/mm/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. 2) I understand that I have the right to inspect and copy the mental health/developmental disability information that will be used or disclosed pursuant to this authorization. I understand that the person(s) or organization(s) authorized to make the requested use and/or disclosure may not condition treatment, payment, enrollment or eligibility for benefits, on execution of this authorization.

It has been explained to me that if I refuse to consent to this release of information, the consequences, if any, will be specified.

With my electronic signature below, I acknowledge and affirm the statements in this authorization form.
Patient's Signature
Date  
(dd/mm/yyyy)
Signature of Minor (12 to 17 inclusive)
Date  
(dd/mm/yyyy)
Parent/Guardian/Representative Signature
Date  
(dd/mm/yyyy)
Relationship to Patient
Applicable fees will be charged for patients and attorneys
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Last Updated 10/06/2009