Medical Records Request Form
As part of your great patient experience at Memorial, Memorial Medical Center's Release of Information Department fulfills requests for medical information.
To request medical records, please submit a completed authorization form (see below) signed by the patient to the Health Information Management Department. Upon receipt of the completed authorization form, we will process your request within two business days.
You may appear in person at Memorial's Health Information Management Department to pick up your records. We are in Room G163 in the Lincoln Zone. You may be able to pick up your records same day as your request, as time permits. Or, records can be mailed directly to your home.
Patients who pick up their records in person will need to bring photo identification. A nominal copying fee may apply.
Memorial's authorization form is available for download below. You will need Adobe Acrobat Reader installed in order to read the downloaded file.
If you would like to request a copy of the form mailed directly to your home or have questions, please feel free to contact the Health Information Management Department at (217) 788-3550.
HIPAA Authorization to Use and Disclose Health Information (Medical Release Form)
Release of Information instruction sheet (This document explains each section of the HIPAA Authorization form.)
Birth Certificate Requests
Please contact the Sangamon County Clerk's Office with birth certificate requests. Call (217) 753-6700, or visit sangamoncountycircuitclerk.org.