Patient Portal

Medical Records Request - Illinois

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
Authorized Relative Certification

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

Fax: 833.384.5921