Medical Records Request

Please complete the following steps to request records:

1. Complete the client information section by providing the client’s information, including a valid phone number the client (or representative) can be reached at.
2. Check the appropriate box according to the location in which client received treatment.
3. Provide the requested information for whom the client would like their records sent to, including their relationship to the client.
4. Indicate how the records are to be sent.
5. Specify the purpose of the disclosure by checking the appropriate box(es).
6. Specify the information to be disclosed by checking the appropriate box(es). Only information checked will be released.
7. The form must be dated and signed by the client (or legal representative) AND witnessed by an adult. *Signature is required.
8. Send the completed form to

The medical records release request form expires 180 days after being signed, unless specified to expire at the time of the disclosure.

If you have any questions regarding how to fill out the authorization form, please call 224-970-1022.