Request for Medical Records

To request a copy of your/your child’s health information, complete an Authorization for Release of Patient Health Information form, and submit it to the Medical Records Department.

Authorization for Release of Patient Health Information Form
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You may submit the request in person from 8 a.m. to 4:30 p.m., or by mail to:

Chicago Lakeshore Hospital
Medical Records Department
4840 North Marine Drive
Chicago, Illinois 60640

You may also fax the request to:
(773) 907-4630

If you or your child are hospitalized, you may submit the form at the front desk of the hospital, upon discharge from the hospital.

How much does it cost to obtain a copy of my/child’s medical records?

• There is no charge for releasing copies of medical records directly to other health providers. (The records must be sent directly to the health care provider’s address.)
• Patients will be charged a $25 fee for paper copies or $15 for disc of record (if applicable) of their medical records.
• To reduce the cost, patients should consider requesting specific information rather than a complete record, or having another party request on their behalf (e.g. social security administration).
• Chicago Lakeshore Hospital contracts with Healthport to process your request for medical records. The following fees apply:

Pages	Cost	Microfilm/Electronic Document
1 - 25	$0.89/page	$1.49/page
26 – 50	$0.59/page	$1.49/page
51 and up	$0.30/page	$1.49/page