If you received care from a physician’s office located in Illinois, please download the appropriate form:
- Request for information by an individual patient
- Third Party Authorization for release of information
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 or fax the form to:
Health Information Release Services – WUPI
660 S. Euclid Ave., CB 1219
St. Louis, MO 63110
Please be patient as you may experience slight delays in the processing and fulfillment of your medical record request through the U.S. Postal Service and other delivery services due to COVID-19.