If you received care from a physician’s office located in Illinois, please download the appropriate form:
Request for information by an individual patient
Third Party Authorization for release of information
For access to a deceased patient's medical records:
Authorized Relative Certification - submit a copy of the medical records request form and a copy of the death certificate with this form.
Please complete the form in its entirety, and sign and date.
Mail or fax the form to:
Health Information Release Services-WUPI
660 South Euclid Ave., Campus Box 1219
St. Louis, MO 63110