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, mail it to Christie Clinic, Medical Records Department, 101 West University, Champaign, Illinois 61820 or fax it 366.1294.
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:
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".
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".
Indicate specifically which records you want to have copied in the black lined box.
State the purpose for your disclosure. Examples: claim determination, workers comp. case, attorney, personal request in "Section C".
Date and sign at the bottom of the form.
If you have questions, please call 217.366.9656 for assistance.
- Authorization to Disclose Health Information (36kb)Authorization to Disclose Health Information Form
- Authorization to Disclose Health Information: Verbal Release (36kb)Authorization to Disclose Health Information: Verbal Release Form
- Life Imaging™ (Radiology) Record Release (68kb)Life Imaging™ (Radiology) Record Release Form