If you received care from a physician’s office located in Illinois, please use the appropriate form:

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