About Your Medical Record

At Elmhurst Memorial Healthcare, we are sensitive to the private nature of a patient’s medical record. We take steps to assure that your medical record is kept confidential and secure.

Who is authorized to sign for the release of a medical record?

A written authorization is required to release a medical record. The following people are authorized to sign for release of a medical record:

  • 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, legal documentation showing appointment as an executor or administrator of an estate, court order or small estate affidavit and a death certificate are required.

How to obtain a medical record

To request a copy of your medical record, please complete the Authorization to Use or Disclose Protected Health Information and deliver in person, mail or fax to:

Medical Record Department
Elmhurst Memorial Hospital
155 E. Brush Hill Road
Elmhurst, IL 60126
Phone: (331) 221-6755
Fax: (331) 221-3726

You can either download the form from this website or call (331) 221-6755 to request a form.

You will need Adobe Acrobat Reader to open this document. If you do not have Adobe Acrobat Reader, you can download a FREE version from the Adobe Web site.

Print/copy fees determined by the state of Illinois will be charged.

Copy rates    
1–25 Pages   $.96 per page
26–50 Pages   $.64 per page
More than 50 pages   $.32 per page
Microfiche or microfilm   $1.60 per page


  • A CD will be provided at 50 percent of the paper copy rate (48 hours notice is required).
  • Payment (cash or check) will be required at the time of receipt of copies or before any copies are mailed to you.
  • Your medical record will be forwarded directly to another health care provider without charge.
  • We automatically send copies of your test results to the physician who ordered the test, so we encourage you to contact him/her to receive and discuss your results.


Location and hours

The Medical Records Department is located on the first floor of the Hospital. You may park in the Green parking lot and enter the building using the East entrance.

We are open:
Monday through Friday 8 a.m.–6 p.m.
Saturday 8 a.m.–Noon
Closed Sundays and Holidays

Elmhurst Memorial Healthcare Network

This site is part of the Elmhurst Memorial Healthcare network of Web sites, which covers a variety of topics using the same philosophy: When it comes to medical care, we know that you have a lot of options. And we want you to know that you're more than a patient to us. You're an individual. We would appreciate the opportunity to provide you with state-of-the-art medical care and down-to-earth, personalized attention.

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