Submit your form:
If you/your child are hospitalized, submit the form upon discharge to Health Information Management, located on the main hospital's 9th floor.
Attn: Release of Information
Ann & Robert H. Lurie Children's Hospital of Chicago
Health Information Management
225 East Chicago Avenue, Box 11
Chicago, IL 60611
Attn: Release of Information
Guidelines for Completing the Print Form
Required Patient Information
- Patient's full name
- Patient's date of birth
- Telephone number
Required Recipient Information
- Leave the “From” area blank unless you are requesting records from another hospital or physician to be sent to Lurie Children's
- Print the name/institution and address to whom you wish your records to be sent; there is no charge for releasing copies of health information directly to other healthcare providers
- Specify the date(s) of treatment for which you are requesting records; documents will be copied for the dates of treatment you specify
- Type of Information Requested
- Select the category or categories of information you specifically want copied
- If the record contains any of the highly confidential items listed, they must be checked off specifically in order to be released
- To reduce your cost, you should consider requesting specific information rather than the complete record (check the “Abstract” box to do this)
Highly Confidential Items
If you would like any of the highly confidential items listed to be included in the release of your records, they must be specifically checked off. Please note the signature requirements listed.
Select or describe the purpose for releasing the information.
Specify the date on which the authorization will expire. If not otherwise specified, it will expire within 30 days of the date of signature, the exception being mental health releases which expire in one year from the date of signature.
If you are the authorized requestor, please sign and date the authorization. Information will not be released without proper signatures.
If your signature cannot be validated, you may be asked to provide supporting documentation that proves your authority to sign the authorization on the behalf of the patient. Please have your signature witnessed.
Common Medical Record Questions
The patient, if 18 years of age or over (not a patient's spouse or a parent of a patient over 18)
The parent or legal guardian, if the patient is younger than 18 years of age, with this exception: if the patient is 12 years or older and requesting a mental health record release, or records containing HIV/AIDS, drug and alcohol, sexually transmitted disease, pregnancy and/or birth control information (According to state law, a patient 12 or over must authorize release of this highly confidential information)
A guardian, if the patient is legally judged incompetent
Emancipated minor (the minor is legally married, is a parent, is pregnant, or has been legally emancipated by the court)
Copies are typically processed within 10 business days. If you have questions, please call Health Information Management at 312.227.5220.
There is no charge for releasing copies of health information directly to other healthcare providers when records are sent directly to the healthcare provider's address.
Families are charged a per page fee for copies of their health information. See chart below.
To reduce the cost, families can consider requesting specific information rather than a complete record, or having another party request on their behalf (i.e., insurance company).
Number of copies Medical Records Microfilm/Electronic Documents
Pages 1-25 $0.96 per page $1.60 per page
Pages 26-50 $0.64 per page $1.60 per page
Pages 51 and up $0.32 per page $1.60 per page
MyChart gives you safe, secure online access to portions of your child's electronic medical record (EMR).
Learn more about MyChart