Medical Records Request

Print and fill out the Release of Information (ROI) Form below:

 
You may submit your request:

  • Via fax to 312-926-3093 (Attention: Health Information Management)
  • Via mail to Health Information Management, 541 N Fairbanks, Suite 1475, Chicago, IL 60611
  • If you need to speak to a representative about the status of your request please call 312-926-3376
  • Print and complete the NMHC Authorization to Obtain Confidential Information form below. 
    NMHC Authorization to Obtain Confidential Information   
    This form is used by NMHC clinical affiliates to obtain health information from outside organizations.  

Patients' Privacy Rights

Under the Health Insurance Portability and Accountability Act (HIPAA), patients have the following rights:

  • To request a change or amendment to their health information if they believe there is an error
  • To obtain a listing of individuals and/or organizations that have received their health information from Northwestern Memorial HealthCare clinical affiliates; this is also known as an Accounting of Disclosures
  • To restrict disclosures of their health information

Please print and complete the appropriate form and submit your request to:

Northwestern Memorial Hospital
Health Information Management
251 East Huron
Lower Concourse / L340
Chicago, IL 60611

NMHC Amendment Request

NMHC Patient Request for Accounting of Disclosure     

NMHC Request for Restriction of Protected Health Information