INSTRUCTIONS FOR COMPLETION OF AUTHORIZATION TO RELEASE/OBTAIN MEDICAL RECORD INFORMATION
Please print and complete all sections of the online form.
The signed completed form must be presented to the Health Information Management (HIM) Department for your request to be processed.
You may present it to the HIM office during the hours of 8:00 am to 4:30 pm, Monday through Friday.
You may submit by FAX (618) 498-8496 or by e-mail. There may be charges associated with your request for records.
You may pick up your records at the HIM Department (allow 7 working days). Please bring personal identification to verify that you are legally entitled to the medical information. We will fax or mail records to another healthcare organization or physician office at your request.
If you have questions, please contact the Health Information Management Department at phone number 618-498-8309.
- Do Not Resuscitate (DNR) Advance Directive
- Living Will Declaration Form
- Permission to Treat Form
- Power of Attorney for Health Care
- DNR Advance Directive Guidance for Individuals
You may also ask your health-care professional about a do-not-resuscitate order (DNR order). A DNR order is a medical treatment order stating that cardiopulmonary resuscitation (CPR) will not be attempted if your heart and/or breathing stops. The law authorizing the development of the form specifies that an individual (or his or her authorized legal representative) may execute the IDPH Uniform DNR Advance Directive directing that resuscitation efforts shall not be attempted. Therefore, a DNR order completed on the IDPH Uniform DNR Advance Directive contains an advance directive made by an individual (or legal representative), and also contains a physician’s order that requires a physician’s signature.
Before a DNR order may be entered into your medical record, either you or another person (your legal guardian, health care power of attorney or surrogate decision maker) must consent to the DNR order. This consent must be witnessed by one person who is 18 years or older. If a DNR order is entered into your medical record, appropriate medical treatment other than CPR will be given to you. This webpage provides a copy of the Illinois Department of Public Health (IDPH) Uniform Do Not Resuscitate (DNR) Advance Directive that may be used by you and your physician. This webpage also provides a link to guidance for individuals, health-care professionals and health-care providers concerning the IDPH Uniform DNR Advance Directive.
A living will tells your health-care professional whether you want death-delaying procedures used if you have a terminal condition and are unable to state your wishes. A living will, unlike a health care power of attorney, only applies if you have a terminal condition. A terminal condition means an incurable and irreversible condition such that death is imminent and the application of any death delaying procedures serves only to prolong the dying process.
Even if you sign a living will, food and water cannot be withdrawn if it would be the only cause of death. Also, if you are pregnant and your health-care professional thinks you could have a live birth, your living will cannot go into effect. You can use a standard living will form or write your own. You may write specific directions about the death-delaying procedures you do or do not want.
Two people must witness your signing of the living will. Your health-care professional cannot be a witness. It is your responsibility to tell your health-care professional if you have a living will if you are able to do so. You can cancel your living will at any time, either by telling someone or by canceling it in writing.
If you have both a health care power of attorney and a living will, the agent you name in your power of attorney will make your health-care decisions unless he or she is unavailable.
Power of Attorney for Health Care
The health care power of attorney lets you choose someone to make health-care decisions for you in the future, if you are no longer able to make these decisions for yourself. You are called the "principal" in the power of attorney form and the person you choose to make decisions is called your "agent." Your agent would make health-care decisions for you if you were no longer able to makes these decisions for yourself. So long as you are able to make these decisions, you will have the power to do so. You may use a standard health care power of attorney form or write your own. You may give your agent specific directions about the health care you do or do not want.
The agent you choose cannot be your health-care professional or other health-care provider. You should have someone who is not your agent witness your signing of the power of attorney.
The power of your agent to make health-care decisions on your behalf is broad. Your agent would be required to follow any specific instructions you give regarding care you want provided or withheld. For example, you can say whether you want all life-sustaining treatments provided in all events; whether and when you want life-sustaining treatment ended; instructions regarding refusal of certain types of treatments on religious or other personal grounds; and instructions regarding anatomical gifts and disposal of remains. Unless you include time limits, the health care power of attorney will continue in effect from the time it is signed until your death. You can cancel your power of attorney at any time, either by telling someone or by canceling it in writing. You can name a backup agent to act if the first one cannot or will not take action. If you want to change your power of attorney, you must do so in writing.