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Online Medical Record Request Form

* Denotes required fields
Palos Community Hospital
12251 S. 80th Avenue
Palos Heights, IL 60463
* It may be necessary to telephone you regarding your authorization. If you are not available, a message identifying the hospital will be left on either your answering machine or with the person answering the phone. Do you give permission for Medical Records to leave the message?
Dates of Service to be Released
* Do you need imaging on a CD?
Do you need your imaging report?
* Do you need pathology slides?
Type of Information Requested:
Please note: To protect your privacy and your records, you will be required to pick up your medical records in person and sign for them. If someone other than the patient will be picking up the medical records, they must have a signed patient authorization form.
* Denotes required fields
The date you submit must be within the next 90 days.

If I fail to supply an expiration date or event, this authorization will expire 90 days from the date it was submitted. I understand that once the information in this form is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. I understand authorizing the use or disclosure of the information identified is voluntary. I need not sign this form to ensure health care treatment.
* Acknowledgement