Forms & Records for Chicago Area Pediatrics Patients

How to Request School/Camp/Athletic Forms

We can provide a State of IL form and/or complete specialty forms based on your needs. Please note:

• Your child must be up to date on their well-visits for us to complete any health forms. Please plan to schedule your visit with time.
• Form requests may take 3-5 business days to complete.
• If you have a specialty form, you may upload it to MyChart, Fax, or drop it off to our office. Due to patient privacy, we can send your reports via MyChart or you can pick them up at our office.
• Please save a copy of your completed forms to avoid delays in future requests. 

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Medical Records Request 

You can request your medical records in the following ways:

MyChart

• Log onto your MyChart account. Under “Menu” search for “Document Center” and click link to request medical records.

Email

• Download and complete the appropriate request form. Scan and email to our office email. The form will need a physical signature to be complete.
• Due to privacy policies, we are unable to email your records back. You can coordinate a time to pick them up or we can send them via MyChart.

You may reach our office with additional questions at 312.227.1160 or capoffice@luriechildrens.org

Medical Records Request Form

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Sending Medical Records to Another Provider

• To send medical records to an outside provider, please download the Medical Records Request form above. The form will need a physical signature to be complete.
• You may scan and email your request forms to our office (CAPoffice@luriechildrens.org).
• Please note, due to privacy policies, we will not be able to send your records via email. We can send them to your new provider via mail, fax, or you can coordinate a time to pick them up.

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Patient Forms

We will need to complete certain forms on an annual basis. You may download, print, and complete these forms at your convenience or complete them via MyChart. 

• Consent for Care and Services
• Federal and State Mandatory Patient Notices
• Plain Language Summary 
• Notice of Privacy Practices Summary
• Patient Registration Form 
• Notice Privacy Practices Pamphlet 
• Minors Accompanied by Someone Other Than Legal Guardian – The purpose of this form is to identify individuals you would allow to bring your child for visits to Lurie Children's Primary Care - Chicago Area Pediatrics and also to authorize the disclosure of information during visits.

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Office Email & Fax Number

Chicago Area Pediatrics

• Fax: 312.227.9680
• Office Email