
⚠ COVID-19 INFORMATION: Resources, Vaccine Information
You can access portions of your child's electronic medical record by signing up for Lurie Children's MyChart.
Note: If your child is a Town & Country Pediatrics patient, please visit the Town & Country Records & Forms page for the proper forms.
You can also request printed medical records by fax, mail or in person. Return the completed form below to Health Information Management.
Authorization for Release of Patient Information Form
Formulario de autorización de entrega de información sobre la salud
Please allow approximately 5-7 business days for the processing of all requests. Hours of Operation: Monday-Friday. 8 a.m.-4:30 p.m. You can reach the Health Information Management Office at 312.227.5220.
In Person
If you/your child are hospitalized, submit the form upon discharge to Health Information Management, located on the main hospital's 9th floor.
Fax
312.227.9733
Attn: Release of Information
Mail
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
Required Patient Information
Required Recipient Information
Date(s) Requested
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.
MyChart gives you safe, secure online access to portions of your child's electronic medical record (EMR).