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Medical Records (Health Information Management) Department

A patient, or his/her legal representative, may inspect and/or obtain a copy of their medical records, or have copies of medical records sent to another facility.

We require a completed and signed Authorization to Release Protected Health Information form before releasing any documents to anyone, including the patient.

If you have questions about this process, please feel free to contact the Health Information Management department directly at 217-762-1860.

To Request a Copy of Your Medical Records

  • Please fill out and print the form: Authorization to Release Protected Health Information
  • The form must be completed, dated and signed by the patient.
  • We ask that you specify what components of your medical records you wish to obtain.
  • Photo ID is required when records are picked up. (records will not be released without this)
  • Individuals other than the patient (such as a guardian or a proxy under a power of attorney) must have documentation of authority to sign.
  • Please note: Your request may take up to 30 days to process.
  • Kirby Medical Center does not charge patients for copies of “pertinent” information, such as History and Physical, Discharge Summary, Operative Report, Laboratory results, or imaging reports. If you are requesting a complete copy (i.e., every page of your chart), we will charge a fee in accordance with Illinois State Comptroller Copying Fees Adjustments.
  • Did you know that for lab results, radiology results, and other information, you can visit your patient portal, Kirby Connect Patient Portal? Sign up here or contact Health Information Management department at 217-762-1860.

Please mail Authorization to Release Protected Health Information form to:

Kirby Medical Center
HIM Department- ROI
1000 Medical Center Drive
Monticello, IL 61856

Fax Authorization to Release Protected Health Information form to:
Attn: Release of Information

Health Information Management (Medical Records) Department Hours

  • Monday to Friday, 8 a.m. to 4:30 p.m.