Please use this form to request access to your Protected Health Information (PHI) in the designated record set that we maintain.

You generally have the right to inspect and/or obtain a copy of your PHI in your designated record set from OSF HealthCare.

Legal Notice

根据法律，我们不需要同意您访问您的PHI值的请求，在某些情况下，法律要求我们拒绝访问。

如果是这样的情况，我们会告知你拒绝的原因。在某些情况下，你可以要求重新考虑拒绝。

Fees

If you request a copy of your records, OSF may charge a reasonable fee based on the cost of labor and materials to produce the copies.

Sensitive Information

If information contains sensitive information such as mental health/developmental disability, sexually transmitted diseases and/or alcohol/drug abuse, genetic testing or HIV/AIDS,2022世界杯赛程安排

*indicates a required field.

First Name: *

Last Name: *

Address: *

City: *

State: *
只有两个(2)字母缩写。

ZIP: *
Five (5) digits only.

Email: *

Phone: *
Please provide the best number to reach you.

Fax:
Please provide if available

Date of Birth: *
Please use MM/DD/YYYY format.

Social Security Number: Last Four Digits: *

Organization

Which hospital are you requesting records from? *
-- Select One --OSF Heart of Mary Medical Center (Urbana)OSF Holy Family Medical Center (Monmouth)OSF Little Company of Mary Medical Center (Evergreen Park)OSF Sacred Heart Medical Center (Danville)OSF Saint Anthony Medical Center (Rockford)OSF Saint Anthony's Health Center (Alton)OSF Saint Clare Medical Center (Princeton)OSF Saint Elizabeth Medical Center (Ottawa)OSF Saint Francis Medical Center (Peoria)OSF Saint James - John W. Albrecht Medical Center (Pontiac)OSF Saint Luke Medical Center (Kewanee)OSF Saint Paul Medical Center (Mendota)OSF St. Francis Hospital & Medical Group (Escanaba)OSF St. Joseph Medical Center (Bloomington)OSF St. Mary Medical Center (Galesburg)

Information to be Disclosed

Date(s) of Visit(s): *

请选择您希望我们分享的信息。 *

• Hospital Visit Record
• Emergency Visit Record
• Lab Results
• Radiology Records
• Other

What type of radiology records are you requesting?

• Results
• Films
• Both Results and Films

If you selected "other" above, please tell us what information you were needing instead.

Delivery

所有请求都将在我们的资源允许的情况下以最快的速度处理和交付。下面列出的时间仅为估计。

Delivery Options: *

• OSF MyChart: less than 3 business days
• Encrypted Email: 3 to 5 business days
• USPS Mail: 3 to 10 business days

Note: the time to process and release is provided for each option.

If sending by USPS MAIL please select format:

• CD/DVD
• Paper

Submit

We respect and safeguard your privacy. This form is secure.