If you received care from a physician’s office located in Illinois, please use the appropriate form:
- Request for information by an individual patient (online form)
- Request for information by an individual patient (printable PDF)
- Third Party Authorization for release of information (printable PDF)
For access to a deceased patient’s medical records
Authorized Relative Certification: Submit a copy of the medical records request form and a copy of the death certificate with this form.
Please complete the form in its entirety, and sign and date.
Mail/fax instructions
Mail or fax the form to:
Health Information Release Services
660 S. Euclid Ave., MSC 1219-35-3
St. Louis, MO 63110
Fax: 833-384-5921