OSF Saint James - John W. Albrecht Medical Center

Pontiac, Illinois

Medical Records

Requesting Medical Records

Please complete each section of the Medical Records Authorization Form and mail or fax it to the OSF Saint James Medical Records department. If the form is incomplete, it may cause a delay in the completion of your request.

Medical Records Authorization Form (PDF - 24.4 KB)

There may be a charge for a copy of your medical records. We will notify you of the fee before sending records, if the fee applies. Please be advised that we may require additional information and identification for patient safety reasons. If you have any questions or concerns please do not hesitate to call us.

Mailing Address
OSF Saint James - John W. Albrecht Medical Center
Attn: Medical Records
2500 W. Reynolds Street
Pontiac, Illinois 61764

Fax Number: (815) 842-4911
Phone Number: (815) 842-4989

Helpful Tips

Please review these instructions to assist in filling out the form:

  • If there is a chance you have records under a different alias please include all to ensure we find all the information being requested.
  • Make sure to specify the dates and information being requested (if you are unsure of exact dates please give an approximate date(s) or list what information you are looking for)
  • Please make sure to check mark and initial the box(s) in the sensitive information section if you have had any of these test completed and wish to have a copy of the results. This information will NOT be disclosed if this has not been completed.
  • If you wish to have a copy of your X-Ray, CT, MRI or Mammogram images/films please contact the Radiology department at (815) 842-4932.
  • If you wish to have a copy of your Itemized Statement, please contact the OSF Patient Accounts & Access Center at (309) 683-6750 or toll-free at (800) 421-5700. Please allow ten (10) days for receipt of the itemized statement.
  • In the 'disclosed to or used by' section please specify if you would like records disclosed to you the patient, another individual, insurance office, attorney or health care facility. Please list their name, address and phone number.
  • If records need to be faxed please include a fax number and specify on the form that records need faxed. We will only fax records by request to other health care facilities and insurance offices. We may be unable to fax certain records depending on the sensitivity of the information and size of the file.
  • If you would like this information disclosed to yourself please write SELF and specify if you would like these records mailed or if you would like to come pick up a copy.
  • Please make sure to sign and date the authorization form to make it valid.
  • If you are a parent signing for a minor child they must be 17 and under. If the patient is over 18 they must sign the authorization form.
  • If you are the patient's Power of Attorney for Health Care, you may sign the authorization form for information on the patient. However, if we do not have this information on file we may ask for a copy to be included with this form. If you are unsure if we have a copy on file please call before submitting this form and we will be glad to check.
  • If you are requesting records on a deceased patient, please contact Release of Information at (815) 842-4989 for more information.