Forms & Records for Town & Country Patients

How to Request School/Camp/Athletic Forms

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

• Your child must be up to date on their well-visits for us to complete any health forms.
• State of Illinois forms (please see link below) may be sent via MyChart.
• All other school, camp, and specialty forms (FMLA) should be sent via USPS, dropped off at the office, or sent via email to your home office:
  • Halsted Office: tcpofficehalsted@luriechildrens.org | Fax: 312.227.9551
  • Skokie Office: tcpofficeskokie@luriechildrens.org | Fax: 312.227.9557
  • Glenview Office: tcpofficeglen@luriechildrens.org | Fax: 312.227.9555
• Please save a copy of your completed form, which is valid for one year from date of well visit.
• Form request can take up to 10 business days to complete. 

Medical Records & Vaccination Records Requests

You can request your medical records and vaccination records in the same manner. Please make sure to use the appropriate form linked below. Also, please note that vaccination records only include vaccination information.

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 medical records 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 medical records at 312.227.2806 or tcprecords@luriechildrens.org. 

Sending Medical Records to Another Provider

• To send medical or vaccination records to an outside provider, please download and complete the appropriate forms above. Both forms require patient signatures and will not be complete without them.
• You may scan and email your request forms to our medical records email (tcprecords@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.

Patient Forms

You 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. Completed pdf forms should be emailed or faxed to your dedicated home office. Please see locations with corresponding information below.

• 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 – Town & Country Pediatrics and also to authorize the disclosure of information during visits.

Office Emails & Fax Numbers

Halsted Office

• Fax: 312.227.9551
• tcpofficehalsted@luriechildrens.org

Skokie Office

• Fax: 312.227.9557
• tcpofficeskokie@luriechildrens.org

Glenview Office

• Fax: 312.227.9555
• tcpofficeglen@luriechildrens.org