A patient’s medical record is the physical property of Jackson Park Hospital And Medical Center. However, the patient has the right to obtain a copy of their medical record. We are happy to provide copies of your medical records upon request. If you are requesting medical records for a physician, we will provide them directly to the physician's office as a professional courtesy at no cost.
Patients who wish to receive a copy of their medical records or to have their records forwarded to another party other than a physician, must fill out and complete the information requested in the Authorization For Release Of Protected Health Information form.
The following people are authorized to sign for release of your health information:
The patient or patient’s legally authorized representative (medical power of attorney must be provided)
The parent of a patient under the age of 18
In the case the patient is deceased, authorization may be from the:
Agent under power of attorney for health care,
Executor of the estate,
Special administrator, or
Next of kin.
A copy of the death certificate and other documentation (such as medical power of attorney) may be required.
Upon completion and execution by an authorized signor, you may mail or personally deliver your Authorization to Jackson Park Hospital and Medical Center’s Health Information Management (HIM) Department.
In order for us to adequately verify your identification and validate your authorization, we require that you include with your request a legible copy of a valid photo I.D. (e.g., driver's license or state I.D.), and your telephone number. Upon receipt of an appropriately completed and signed Authorization Form, the HIM’s department will process the request.
In accordance with Illinois state law, the hospital charges a fee for copying the medical record. You will be invoiced for payment of the copies. After full payment is received, the copies will be processed, mailed or made available to the patient or a designated individual for pickup. Please allow five to ten business days for processing of your request.
For assistance with completing the Authorization For Release Of Protected Health Information form or if you have any questions, please call the Health Information Management Department at (773) 947-7550. Our office hours are 9:00 am to 4:00 pm Monday through Friday.
Jackson Park Hospital
& Medical Center
7531 Stony Island Avenue
Chicago, Illinois 60649
Telephone: (773) 947-7500