Request Medical Records

All medical record requests will be processed by our release of information vendor partner Vital Chart.

Option 1: In Person– You may visit the Health Information Management Department between the 8am to 4pm. Please arrive no later than 15 minutes before closing time and bring a valid, government issued photo ID. You may enter South Shore Hospital from the main entrance at 80th and Crandon Avenue. Please stop at the security desk for directions to the department.

Option 2: Via Mail– You may fill out a downloaded copy of the authorization form below. Please complete the form legibly, sign your signature neatly on the form and send it in along with a legible copy of a government issued photo ID. Please mail your completed documents to:

South Shore Hospital
Attn: Health Information Department
8012 S. Crandon Avenue
Chicago, Il 60617

Option 3: Via Fax– You may fax a completed, legible authorization for release form along with a clear copy of your government issued photo ID to 773-356-5155. This option is for patients only. Legal requests must be mailed to the address above.

Please download the authorization form below:
Authorization for Release of Information form and follow the guidelines for completion.

Guidelines for completing the authorization for release form:

To avoid a delay in fulfilling your request, a valid authorization MUST include the following information:

• Patient’s full name (Please list any other names, suffixes or middle initial (e.g. maiden name or Jr.) used at the time of admission or treatment.
• Patient’s date of birth.
• Patient’s full address and phone number
• Date(s) of treatment or services requested.
• Reason for your request.
• Name of the person, facility or provider the information is to be released to.
• Select the method of release. (We will fax to another hospital or physician office, but we will not fax to a home or business).
• Specify the information requested.
• Patient’s signature or patient’s legal representative’s signature. (Authorizations signed by a patient representative must have accompanying documentation. Records will not be released without valid signature(s)/ or documentation (if applicable).

A valid signature includes:

• The patient, if they are 18 years or older.
• The parent or legal guardian, if the patient is younger than 18 years of age, with the exception of highly confidential information, such as mental health records, records containing HIV/AIDS, drug and alcohol, sexually transmitted disease, pregnancy and/or birth control information. State law requires patients 12 and older to authorize the release of this highly confidential information.
• A guardian, if the patient has been legally deemed incompetent. Documentation must be provided to prove guardianship.
• Emancipated minors. Documentation required.
• In the event the patient is unable to sign, documentation of Power of Attorney for Healthcare is required.
• Requests for medical records of deceased patients require a copy of the death certificate, evidence of next of kin, or evidence of executorship of the estate or administrator of the estate. Please contact Vital Chart for more information at 312-757-5020

FEES FOR MEDICAL RECORDS:

Requests for personal use:

• There is a fee for the copying and processing of records for personal use. Please see the fee schedule fee schedule.
• Please allow a reasonable amount of time to process your request. Typically, requests are processed within 7-10 business days. A Vital Chart representative will contact if there are any barriers to processing your request.
• Records will be mailed to the address specified by you on the authorization form. You may also decide to pick up your records in person. Please call the Release of Information staff at 773-356-5246 before visiting our office. For security reasons, you will be asked to provide a state or federally issued photo ID. We will not release records to individuals who are NOT the patient. Please call 773-356-5246 if you have questions about special circumstances.

Requests for continuity of medical care:

* Complete the authorization for release request form provided by your health care provider’s office. They can fax your signed authorization form to 773-356-5155. There is NO charge for this service.

• Alternatively, you can download, complete and submit the Authorization for Release of Information form in person at our office. You will need the healthcare provider’s address, phone number and fax number, along with your valid government issued ID.
• Medical emergencies will be faxed upon confirmation of patient’s presence at another health care facility (i.e. Face Sheet).
• Continuing care requests are FREE of charge and will be mailed or faxed to your health care provider prior to your appointment. Please indicate the date of your appointment to allow for time to process your request.
• Pertinent information such as radiology/imaging, history and physical, consultations, operative reports, discharge summaries, laboratory results, and ER reports are routinely provided to the physician for continuation of care.

The cost is determined per page and dependent on the purpose for which the record is requested:

• There is NO charge for information to be sent from our facility directly to another hospital or physician (continued medical care).
• Patients/requestors (personal use) will be charged a per page fee for copies according to the State of Illinois fee schedule. The handling fee does not apply to patients or continuity of care requests.
• To reduce the cost you, you may request an “Abstract” or have your provider request the record on your behalf.

Please mail the completed authorization form and a copy of your government issued ID to:

South Shore Hospital
Attn: Health Information Management Department
8012 S. Crandon Avenue
Chicago, IL 60617

OR

Please fax the completed authorization form and a copy of your government issued ID to:

773-356-5155

OR

Arrive in person along with a government issued ID between the hours of 8am and 3:45pm at:

South Shore Hospital
Attn: Health Information Management Department
8012 S. Crandon Avenue
Chicago, IL 60617

Please contact our release of information partners at Vital Chart by calling 312-757-5020.

Requests of highly confidential information, such as mental health records, records containing HIV/AIDS, drug and alcohol, sexually transmitted disease, pregnancy and/or birth control information, please pay special attention to the “Information to be Disclosed” section of the authorization form. Be sure to check the applicable boxes for any information you do NOT want released.

You may exercise your right to pick up such highly confidential portions of your medical records in person.

Per State law, a patient 12 years of age and older with medical records containing highly confidential information, such as mental health records, records containing HIV/AIDS, drug and alcohol, sexually transmitted disease, pregnancy and/or birth control information are required to sign the authorization to release form. The parent or legal guardian, will NOT be able to sign the release of information authorization form on behalf of their child.

South Shore Hospital does not issue or keep copies of birth certificates or death certificates. To obtain a copy of a birth certificate or a death certificate you will need to visit the Illinois State Vital Statistics Bureau at online: https://www.cookcountyclerk.com/agency/vital-records

OR

In person at:

Cook County Clerk’s Office

Cook County Clerk
69 W. Washington, Suite 500
Chicago, IL 60602

REQUEST FOR DIAGNOSTIC IMAGES:

Contact the Radiology Department directly at (773) 356-5325, 5326, 5327, or 5328. You may speak with anyone in the department and provide the following information:

• Patient’s full name (Please list any other names, suffixes or middle initial (e.g. maiden name or Jr.) used at the time of admission or treatment.
• Patient’s date of birth.
• Patient’s full address and phone number
• Date(s) of treatment or services requested.
• Reason for your request.

Please allow a reasonable amount of time to process requests, typically 5-10 business days. Radiology will make your CD and have it ready when you come in with the required fee. Please see the attached DIAGNOSTIC IMAGES FEES (PDF)