Records and Forms

Instructions for Completing the Authorization Form

Provide your full name, date of birth, and a phone number where you can be reached during business hours.

Complete the numbered blanks as follows:

  1. Enter the name of the organization/facility/person with the information to be disclosed. If this is not Christie Clinic, provide the full address in "Section A".
  2. Enter the name of the organization/facility/person you want the records sent to. Again, provide the full address if this is not Christie Clinic in "Section B".
  3. Indicate specifically which records you want to have copied in the black lined box.
  4. State the purpose for your disclosure. Examples: claim determination, workers comp. case, attorney, personal request in "Section C".
  5. Date and sign at the bottom of the form.

Download authorization form here.

If you have questions, please call 217.366.9656 for assistance.