Please use this form to request access to your Protected Health Information (PHI) in the designated record set that we maintain.

You generally have the right to inspect and/or obtain a copy of your PHI in your designated record set from OSF HealthCare.

Legal Notice

By law, we are not required to agree with your request for access to your PHI, and in certain situations, the law requires us to deny access.

If this is the situation, we will advise you of the reason for the denial. Under certain circumstances, you may be able to request a review of the denial.

Fees

If you request a copy of your records, OSF may charge a reasonable fee based on the cost of labor and materials to produce the copies.

Sensitive Information

If information contains sensitive information such as mental health/developmental disability, sexually transmitted diseases and/or alcohol/drug abuse, genetic testing or HIV/AIDS,please use our third-party authorization form process.

*indicates a required field.

First Name: *

Last Name: *

Address: *

City: *

State: *
Two (2) letter abbreviations only.

ZIP: *
Five (5) digits only.

Email: *

Phone: *
Please provide the best number to reach you.

Fax:
Please provide if available

Date of Birth: *
Please use MM/DD/YYYY format.

Social Security Number: Last Four Digits: *

Organization

Which hospital are you requesting records from? *
-- Select One --玛丽OSF心脏医学中心(乌尔班纳)OSF Holy Family Medical Center (Monmouth)OSF Little Company of Mary Medical Center (Evergreen Park)OSF Sacred Heart Medical Center (Danville)OSF Saint Anthony Medical Center (Rockford)OSF圣安东尼健康中心(Alton)OSF Saint Clare Medical Center (Princeton)OSF Saint Elizabeth Medical Center (Ottawa)OSF Saint Francis Medical Center (Peoria)OSF Saint James - John W. Albrecht Medical Center (Pontiac)OSF Saint Luke Medical Center (Kewanee)OSF Saint Paul Medical Center (Mendota)OSF St. Francis Hospital & Medical Group (Escanaba)OSF St. Joseph Medical Center (Bloomington)OSF St. Mary Medical Center (Galesburg)

Information to be Disclosed

Date(s) of Visit(s): *

Select the information you would like us to share. *

• Hospital Visit Record
• Emergency Visit Record
• Lab Results
• Radiology Records
• Other

What type of radiology records are you requesting?

• Results
• Films
• Both Results and Films

If you selected "other" above, please tell us what information you were needing instead.

Delivery

All requests will be processed and delivered as quickly as our resources allow. Times listed below are estimates only.

Delivery Options: *

• OSF MyChart: less than 3 business days
• Encrypted Email: 3 to 5 business days
• USPS Mail: 3 to 10 business days

Note: the time to process and release is provided for each option.

If sending by USPS MAIL please select format:

• CD/DVD
• Paper

Submit

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