Please download the Authorization for Release of Information [PDF] form and follow the guidelines for completion or you may also send us an email.
Authorizations must contain the following to avoid the request being returned:
- Name of person the information is to be released to.
- Patient's full name (list any other names, such as maiden name, the patient may have had).
- Patient's date of birth.
- Date(s) of treatment or services you are requesting.
- Purpose for which the information is being utilized.
- Method of release. We will fax to another hospital or physician office, but we will not fax to a home or business.
- Specific information requested.
- Patient's signature or patient's legal representative's signature. Authorizations signed by a patient representative must have accompanying documentation. Records will not be released without valid signature(s) /documentation (if applicable).
Requests for personal use:
- Complete and submit the Authorization for Release of Information form.
- There is a fee for the copies and processing of records for personal use. Please see the section on cost below.
- Please allow reasonable time to process your request. Typical requests are processed within 10 business days. We will contact you in the event unforeseen delays or difficulty processing your request.
- Records will be mailed to the address specified on the authorization form. You may make arrangements with the Release of Information staff in the event you would like to pick them up. For security reasons, you will be asked to provide a state or federally issued photo id to pick up records. Unless arrangements are made in advance, we will not release records to individuals who are not the patient.
Requests for continuing medical care:
- Complete and submit the Authorization for Release of Information form, or complete the request form from the physician or other health care provider's office.
- Medical emergencies will be faxed upon confirmation of patient's presence at another health care facility (i.e. Face Sheet).
- Continuing care requests are free of charge and will be mailed or faxed to your physician/the facility prior to your appointment. Please indicate the date of your appointment to allow for time to process your request.
- Pertinent information such as radiology/imaging, history and physical, consultations, operative reports, discharge summaries, laboratory results, and ER reports are routinely provided to the physician for continuation of care.
Who is authorized to sign for release?
A valid signature includes:
- The patient, if they are 18 years or older.
- The parent or legal guardian, if the patient is younger than 18 years of age, with the exception of highly confidential information, such as mental health records, records containing HIV/AIDS, drug and alcohol, sexually transmitted disease, pregnancy and/or birth control information. State law requires patients 12 and older to authorize the release of this highly confidential information.
- A guardian, if the patient has been legally deemed incompetent. Documentation must be provided to prove guardianship.
- Emancipated minors.
- Power of Attorney for Healthcare, in the event the patient is unable to sign.
- Requests for medical records of deceased patients require a copy of the death certificate or evidence of next of kin or executorship of the estate.
Where do I take or mail the authorization form?
Submit the completed form to the Health Information Management Department as follows.
Advocate South Suburban Hospital
17800 S Kedzie Ave
Hazel Crest, IL 60429
Attn: Release of Information
Our walk-up window is open Monday through Friday from 8 a.m. to 4:30 p.m. Please enter the hospital through the main entrance and ask for assistance in locating our department.
How can I get a birth or death certificate?
You can obtain a birth or death certificate through the Cook County Clerk of the Circuit Court.
Contact information includes:
What if the information is highly confidential?
Highly confidential items may need an additional authorization from the patient.
How much will it cost?
- The cost is dependent on the type of use.
- There is no charge for information to be sent from our facility directly to another hospital or physician (continued medical care).
- Patients/requestors (personal use) will be charged a per page fee for copies according to the State of Illinois fee schedule. https://illinoiscomptroller.gov/agencies/resource-library/statutorily-required/copying-fees-adjustments/ (See below.) The handling fee does not apply.
- To reduce the cost, you may request an Abstract or have another party request the record on your behalf (i.e. insurance company).
Annual adjustment of copying fees as required under 735 ILCS 5/8-2006:
Fee
Copy pages 1 through 25
Copy pages 26 through 50
Copy pages in excess of 50
Copies made from microfiche or microfilm
