Medical Record Requests
Please fill out the form below to request a copy of your medical records.
IMPORTANT:
Records can
ONLY
be sent via secure email or fax.
We aim to process and return requested records within
3–5 business days
.
If email delivery is requested, a separate password email will be sent to access the secure records.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number (in case we need to contact you about your request)
*
-
Area Code
Phone Number
Fax Number (required if fax is preferred delivery method)
-
Area Code
Phone Number
Patient's Name (if different than the requester)
First Name
Last Name
Relationship to Patient
(Ex. Parent or Guardian)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Location Visited
*
Archer Heights, Chicago, IL
Aurora, IL
Belmont Cragin, Chicago, IL
Blue Island, IL
Bolingbrook, IL
Bourbonnais, IL
Burbank, IL
Calumet Park, IL
Carol Stream, IL
Cedar Lake, IN
Chicago Ridge, IL
Cicero, IL
Crown Point on 109th & Broadway, IN
Crown Point on Burr & 30, IN
Dyer, IN
Elmhurst on Butterfield, IL
Elmhurst on York Street, IL
Evergreen Park, IL
Gage Park, Chicago, IL
Garfield Ridge, Chicago, IL
Griffith, IN
Griffith next to Walgreens, IN
Hammond on 5th Avenue, IN
Hammond on Sibley, IN
Hobart, IN
Hyde Park, IL
Lakeview, Chicago, IL
Logan Square, Chicago, IL
Lombard, IL
Matteson, IL
Mayfair, Chicago, IL
Melrose Park, IL
Merrillville, IN
Merrillville next to Walgreens, IN
Michigan City, IN
Mt. Greenwood, Chicago, IL
Munster, IN
Norridge, IL
Northbrook, IL
Oak Forest, IL
Portage, IN
Portage next to Walgreens, IN
Portage Park, Chicago, IL
Richton Park, IL
River Forest, IL
River North, Chicago, IL
Rogers Park, Chicago, IL
Roscoe Village, Chicago, IL
Schererville, IN
Skokie, IL
Tinley Park on Harlem, IL
Tinley Park on LaGrange, IL
West Loop, Chicago, IL
Westmont, IL
Wheaton, IL
Wicker Park, Chicago, IL
Willowbrook, IL
Date of Requested Visit
*
-
Month
-
Day
Year
Date
Specific Information Requested
*
Questions or Comments?
*
I authorize Midwest Express Clinic to release my medical records directly to me. I understand that this may include sensitive information such as test results, diagnoses, treatments, and any other medical history maintained by Midwest Express Clinic. I have reviewed Midwest Express Clinic's Notice of Privacy Practices at https://midwestexpressclinic.com/hipaa/. I am requesting these records and understand that once released, they may no longer be protected under HIPAA.
Submit
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