Christie Clinic - Medicine for Your Life

Records and Forms

If you need to request your medical records, click on the link below. A PDF will pop up on your screen. Print this form, fill it out, and bring it in or mail it to Christie Clinic, Medical Records Department, 101 West University, Champaign, Illinois 61820.

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, and mark the appropriate line indicating whether we should mail the records or you plan to pick them up.

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.

  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.

  3. Indicate specifically which records you want to have copied. Examples: all pediatric records, ortho records regarding shoulder injury, obstetrical records from 2000 to present.

  4. State the purpose for your disclosure. Examples: claim determination, workers comp. case, attorney, personal request.

  5. Review paragraph 5, and initial it if you agree with the statement. (If this is not initialed and there is any reference to confidential diagnoses, we will not be able to comply with your request.)

  6. Review, and make any changes you feel necessary.

  7. Review.

  8. Review the remainder of the form; sign it, and date it. If you are not the patient, please indicate your relationship to the patient.

If you have questions, please call 217.366.9656 for assistance.

Downloads

Tags: medical records, forms, records

Christie Clinic Champaign on University Photo Champaign on University
101 West University Avenue Champaign, IL 61820 Main Phone: 217.366.1200
Billing Services: 217.366.1382
Toll Free: 888.391.0412
Christie Clinic Champaign on Windsor Photo Champaign on Windsor
1801 West Windsor Road Champaign, IL 61822 217.366.8000
Christie Clinic Christie Clinic at Provena Covenant Photo Christie Clinic at Provena Covenant
1400 West Park Street Urbana, IL 61801 217.366.1200
Christie Clinic Rantoul Photo Rantoul
209 West Borman Drive Rantoul, IL 61866 217.892.9671
Christie Clinic Mahomet Photo Mahomet
1001 Commercial Drive Mahomet, IL 61853 217.586.6600
Christie Clinic Danville on Vermilion Photo Danville on Vermilion
3545 North Vermilion Street Danville, IL 61832 217.442.8611
Christie Clinic Tuscola Photo Tuscola
300 North Main Street Tuscola, IL 61953 217.253.9258
Christie Clinic C U Sleep Photo C U Sleep
1207 South Mattis Avenue Champaign, IL 61821 217.355.1684
Christie Clinic Christie Clinic Cancer Center Photo Christie Clinic Cancer Center
109 West University Avenue Champaign, IL 61820 217.366.5180
Christie Clinic Urbana on Windsor Photo Urbana on Windsor
1710 East Windsor Road Urbana, IL 61802 217.344.9440
Christie Clinic Convenient Care in County Market (Kirby & Duncan) Photo Convenient Care in County Market (Kirby & Duncan)
2901 West Kirby Avenue Champaign, IL 61821 217.366.8130
Christie Clinic Danville on Sheridan Photo Danville on Sheridan
405 Sheridan Street Danville, IL 61832 217.431.6330
Christie Clinic Danville on Logan Photo Danville on Logan
800 North Logan Avenue Danville, IL 61832 217.431.8930
Christie Clinic Urbana on Gregory Photo Urbana on Gregory
700 South Gregory Street, Suite A Urbana, IL 61801 217.328.2323
Christie Clinic Champaign on Fox Drive Photo Champaign on Fox Drive
2110 Fox Drive Champaign, IL 61820
Christie Clinic Arthur Photo Arthur
431 West Palmer Arthur, IL 61911
Christie Clinic Kirby Medical Group Photo Kirby Medical Group
1109 A. North State Street Monticello, IL 61856 217.366.1304
Gibson Area Hospital
1120 N Melvin Gibson City, IL 60936 217.784.2240
Christie Clinic Tuscola at Jarman Photo Tuscola at Jarman
704 North Main Street Tuscola, IL 61953 217.253.9258