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Central Intake: (708) 647-3333
Operating Hours: Monday-Friday, 9am - 5pm

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 Fill out the form below to get started.

Medical Request Form 

I understand that I will be charged a reasonable, cost-based fee for a paper reproduction of the records and the fee must be paid prior to receiving the records. Costs are as follows:
$1.26 per page (pages 1-25)
$.84 per page (pages 26-50)
$.42 per page (pages in excess of 50)
$33.60 for the preparation of a summary of my records
I understand that my request may be granted or denied.  In either event, my request will be responded to within thirty (30) days for records maintained on-site or sixty (60) days for records stored off-site, unless I am notified of an extension.  I understand that if my request is denied, I may be able to request a review of the denial.

Serving Greater Chicagoland, Northwest Indiana, and surrounding communities.