Your personal health information is a valuable resource to you, your family and the health care professionals who provide your treatment and care.
The Adventist La Grange Memorial Hospital Health Information Management (HIM) Department ensures that accurate, complete and dependable health information is available for the care you receive in our facilities. It also retains the health information according to state and federal laws and makes it available to our patients.
How To Request Your Medical Records
Medical records are available two ways:
- Free online access: Create an online patient account for a safe, simple way to access information from your electronic health record (EHR). For privacy and security reasons, some records will not be available online.
- Paper copies: Copies of medical records may be released upon receipt of written authorization of the patient or guardian. Charges apply.
Free Online Access to Your Records
Patients over the age of 18, or a legal guardian, can easily view and download information from their electronic health record at no charge by creating a patient account online.
For some hospitals or physician offices, your online account will also give you access to secure patient-to-doctor messaging. Additional planned features include online scheduling and prescription renewal.
Create a free account now
Sign in to your account
What information can I access online?
*Excluding infectious diseases, toxicology and pregnancy labs.
Request Paper Copies of your Records
Paper copies of your records can be accessed from our HIM department by following the steps below.
Download and Complete the Form Below
Medical Records Authorization Form (English)
Medical Records Authorization Form (Spanish)
A valid authorization must contain the following information or the request will be returned:
- Name of person the information is to be released to.
- Patient's full name (list any other names, such as maiden name, the patient may have had).
- Patient's date of birth.
- Date(s) of treatment or services you are requesting.
- Purpose for which the information is being utilized.
- Method of release. We will fax to another hospital or physician office, but we will not fax to a home or business.
- Specific information requested.
- Patient's signature or patient's legal representative's signature. Authorizations signed by a patient representative must have accompanying documentation of that person's legal authority. Records will not be released without valid signature(s).
Requests for Personal Use:
- Complete and submit the Authorization for Release of Information form.
- There is a fee for the copies and processing of records for personal use. Please see the section on cost below.
- Please allow reasonable time to process your request. Typical requests are processed within 48 hours (law allows up to 30 days). We will contact you in the event of unforeseen delays or difficulty processing your request.
- Records will be mailed to the address specified on the authorization form. You may make arrangements with the Release of Information staff in the event you would like to pick them up. For security reasons, you will be asked to provide a state or federally issued photo I.D. to pick up records. Unless arrangements are made in advance, we will not release records to individuals other than the patient or legally authorized representative of the patient.
Requests for Continuing Medical Care:
- Complete and submit the Authorization for Release of Information form, or complete the request form from the physician or other health care provider's office.
- Personal health information for the treatment of medical emergencies will be faxed upon confirmation of patient's presence at another health care facility (i.e. medical information to support the care provided).
- Continuing care requests are free of charge and will be mailed or faxed to your physician/the facility when requested. Please allow at least 48 hours time to process your request.
Who is Authorized to Sign for Release?
A valid signature includes:
- The patient, if they are 18 years or older.
- The parent or legal guardian, if the patient is younger than 18 years of age, with the exception of highly confidential information, such as mental health records, records containing HIV/AIDS, drug and alcohol, sexually transmitted disease, pregnancy and/or birth control information. State law requires patients 12 and older to authorize the release of this highly confidential information.
- A guardian, if the patient has been legally deemed incompetent. Documentation must be provided to prove guardianship.
- Emancipated minors.
- Power of Attorney for Healthcare, in the event the patient is unable to sign.
- Requests for medical records of deceased patients require a copy of the death certificate and evidence of next of kin or executorship of the estate.
How Much Will It Cost?
The cost of requesting records is dependent on the purpose of the request:
- There is no charge for information to be sent from our facility directly to another hospital or physician (continued medical care).
- Patients/requestors asking for records (personal use) will be charged a per page fee for copies. These allowable fees are governed by state and federal laws. An invoice will be generated at the time records are printed.
Please call (708) 245-8500 for information on payment options.
|Copy pages 1-25
|Copy pages 26 through 50
|Copy pages 51 and above
|Copies made from Microfiche
||$0.66 for the first page, $0.42 for additional pages
How to Return the Authorization Form
|Adventist La Grange Memorial Hospital
Attn: Health Information Management
5101 South Willow Springs Road.
La Grange, IL 60525
||Adventist La Grange Memorial Hospital
Health Information Management Department
Monday thru Thursday - 8 a.m. to 4:30 p.m
Friday - 8 a.m. to 4 p.m..
Saturday - 9 a.m. - 3 p.m.
Call (708) 245-8500 with questions
How to Request a Birth Certificate or Death Certificate
Adventist La Grange Memorial Hospital does not provide copies of birth or death certificates. For information about how to obtain a copy of a birth or death certificate, please contact the Cook County Health Department at (708) 245-8500 or visit the following links:
Cook County Birth Certificates
Cook County Death Certificates
Please feel free to call us at (708) 245-8500 with any questions or concerns.
We look forward to assisting you with your medical record needs.