Medical Records & Forms Requests

Medical records are the property of Northwest Healthcare Associates. Because we adhere to strict confidentiality regulations (HIPAA), we must receive a written request form with your original signature and a copy of your driver’s license in order to release or forward your records. This request must include the patient’s full legal name, date of birth, Social Security number, and the full name, complete address and phone number of the physician/facility where the information is to be sent. There is no charge to have your medical records sent directly to another physician’s office or medical institution.

Our physicians and office staff receive frequent requests to write, complete, and/or send various letters, forms, medical records, and other paperwork for our patients. We are happy to provide these services and can often provide them at no charge if requested during an office visit. Otherwise, we charge a minimum of $10.00 for completing a form or letter. The fee is higher for longer letters and forms that require a summary of your medical history. We also charge a fee for copying, handling, and mailing medical records at the rates established by Illinois law. If you require any of these administrative services, please ask our office staff about current fees.

Forms

Patient Registration Form – New Patients (Click here for our downloadable form) and bring with you to your first visit.

Notice of Privacy Practices – Your privacy is important to us. (Click here for our downloadable form)

Authorization for Release of Confidential Health Information – (Click here for our downloadable form)

Medicare Wellness Visit Form – (Click here for our downloadable form)

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