Please complete each section of the
Medical Record Authorization Form (PDF - 36.2 KB)
and mail or fax it to the OSF St. Joseph Medical Records Department. If the form is incomplete it may cause a delay in the completion of your request.
OSF St. Joseph Medical Center
Attn: Medical Records
2200 E. Washington Street
Bloomington, Illinois 61701
Fax Number: (309) 662-2103
Phone Number: (309) 665-5992
Please Note: 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 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 please contact Radiology at (309) 662-3311 x4780.
- 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 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 (309) 665-5992 for more information.
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 (309) 665-5992.