To request your medical records, please print and complete a release form and return to Carle Foundation Hospital.

• Patient information Release Authorization Form 
• Patient Information Release Authorization Espanol 
• Patient Mental Health Records Release Authorization Form 
• Addiction Recovery Release Authorization Form 

• Patient Name: Please enter the "patient" s current legal name.
• Date of Birth: Please print the patient birthdate. Example: 03/04/1956
• Other Names: Please list any previous names we may have records under. Examples are additional married names, a maiden name, an adoptive name, a name change.
• MRN: This is the patient medical record number which is also known at Carle as a clinic number.

Where do the records need to go?
This section tells Carle where to send the records.

• I authorize: Select the location(s) where the visit(s) took place.
• To Release to: Check this box if Carle should send a copy of the records to another party. Tell us exactly who should receive a copy of the records. Be specific and include a complete address. Please write "Myself" to indicate you, the patient, will be receiving the records.
• To Request from: Check this box if the requested records are to be sent to Carle from another organization. Be specific and include a complete address.

Method of Release: How should the copies to be sent?

• Mail - The records will be sent by U.S. Mail to the party listed.
• Pick up - The records will be held for pick up at the Farber Drive location for 60 days.
• MyCarle Account - for patient requests only. We can release the requested records to the patient's MyCarle Account. They can be saved or printed using a home computer. The records will be available in MyCarle for 30 days.
• Don't have a MyCarle account? Here's how to get one:

Carefully read the bulleted paragraphs, so that you know what you are signing. If you have questions, please call (217) 383-3381.

Signature and address: Please read the ATTENTION: section. You'll need to sign and date the form. Enter your address at the bottom.

Mental health records may require special authorizations, signatures or releases. Please call our Health Information Management department at (217) 383-3381 for more information.

The authorization will expire one year from the date signed unless otherwise specified. If you have any questions about completing forms or obtaining copies of medical records, call Health Information Management at (217) 383-3381.