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.
Record Copy Fees
There are no fees associated with requests for records to be sent directly to another medical provider outside of Christie Clinic.
There may be fees associated for requests sent to you or someone who is not a medical provider. Christie Clinic uses a third party copy service, QuestHIMS, to ensure timely service and to provide greater access to medical record copies. Copies can be provided in paper or electronically (email, CD, flash drive, upload).
For more information or to receive an estimate, please call (217) 366-9656 and a Health Information Systems team member will assist you.