To maintain patient confidentiality and assure compliance with federal and state privacy laws, health information may not be released without a patient’s written authorization (except as permitted by law). Aunt Martha’s partners with Healthport for the release of medical information. The information below describes the process of requesting medical records that you may have at Aunt Martha’s Youth Service Center. The steps involved depend on what records you want provided and/or for whom you want your records provided to.
In most cases, you will need to download and submit the following documents:
Acknowledgement of Medical Record Request Processing Fee / Reconocimiento del cargo por procesamiento de la solicitud de registros médicos
- Acknowledgement of Medical Record Request Processing Fee
- Reconocimiento del cargo por procesamiento de la solicitud de registros médicos
Request and Authorization to Release Health Information / Peticion Y Autorizacion Para Liberacion Y Uso De Informacion Medica
- Request and Authorization to Release Health Information
- Peticion Y Autorizacion Para Liberacion Y Uso De Informacion Medica
Signed and completed authorization forms may be submitted in person, by fax or by mail:
In Person
Drop off the form at one of our AMYSC Health Centers
By Fax (with copy of ID)
708.747.7928
By Mail
Aunt Martha’s Youth Service Center
ATTN: Medical Records
19990 Governors Hwy
Olympia Fields, IL 60461
Please note:
If you completed Release of Information Form and would like to inquire about the status of your request, please contact Healthport at 800-367-1500.
Records involving HIV testing, mental health counseling or alcohol and drug abuse information can only be released with a specific request from you.
Mental health notes must be reviewed by a mental health provider before being released.
Records beyond 7 years of last visit may not be available.
