Obtain a Copy of
Your Medical Records
In order to protect your privacy, Hospice & Palliative Care of Northeastern Illinois (HPNI) requires written authorization to release your medical records to another person or organization. Below is the Authorization to Use and Disclose Individually Identifiable Health Information form, which you can print, fill out, and return to the Medical Records department via fax or mail.
Click Here to Open the Records Disclosure Authorization Form
Frequently Asked Questions for Release of Information
1. Who is authorized to sign for release of my health information?
The following people are authorized to sign for release of your health information:
- The patient or the patient’s legally authorized representative (legal documents must be provided);
- The parent of a patient under the age of 18;
- If the patient is deceased, authorization may be from the agent under power of attorney for healthcare (a copy of a death certificate may be required); the executor of the estate; special administrator; or next of kin*.
* The next of kin, upon presentation of a notarized Small Estate Affidavit, which is available from the Medical Records Department.
2. How much does it cost to obtain a copy of my health information?
HPNI shall copy and release the protected health information. A copy fee will be assessed based on the Annual Adjustment of Copying Fees as required under 735 ILCS 5/8-2006. Current fees can be found on the Illinois Health Information Management Association’s (ILHIMA) website: http://ilhima.org/
Annual adjustment of copying fees as required under 735 ILCS 5/8-2006
Fee 2011
Handling Charge $ 24.81
Pages 1 – 25 $ 0.93 per page
Pages 26 – 50 $ 0.62 per page
Pages 51 and up $ 0.31 per page
Copies made from microfiche or microfilm $ 1.55
For more information, contact a member of our Medical Records staff at 847-381-5599.
