Medical Records Authorization Forms

 

Blessing Health offers an online records request tool that verifies your identity by asking for a photo of your driver's license, which can be taken via webcam or smartphone. There is no additional charge to use this service. Please note, Chrome, Safari and Firefox are the recommended browsers for this application.

If you prefer to print a request form then the below form is used for requesting a copy of your health information for your own use or for transferring of records.

Print a request form here: Release of Information Authorization form

Instructions to complete the form will print with the release form or contact us at 217-223-8400 ext. 6600 to speak with one of our team members. Thorough completion of the form will expedite the record request process.

Alternatively, we offer several other options to deliver your medical records, including:

  • Secure Email (our fastest option): Please call us at 217-223-8400 ext. 6600.
  • Fax: 217-214-5890
  • Mail
    • Attn: Health Information Management
      PO Box 7005
      Quincy, IL 62305-7005
  • On-campus pickup (We will notify you when records have been sent or are ready for pickup.)
    • Cashier’s office at Blessing Physician Services, Suite 106
    • Main corridor outside of the Pharmacy at the Hannibal Walk-In Clinic
  • In Person
    • Completed forms may be brought to the cashier’s office Monday-Friday, 8:00 a.m.-5:00 p.m. If presenting in person, records should take approximately 30 minutes.
    • Patients may also visit the Blessing Resource Center, located at 420 N. 34th Street in Quincy.

Patients may be charged a flat fee of $6.50 for records requests in the following circumstances:

  • Requesting a complete medical record that includes more documentation than just an abstract of hospitalizations within the last 6 months and is not for continuing care will be charged a flat fee of $6.50.
  • Requesting older than 6 months, abstract or complete, that are not part of continuing care, will be charged a flat fee of $6.50.

Transferring to Another Provider 

Records can be emailed, faxed or mailed to provider of your choice. Please let us know your appointment date so we can arrange for records to be delivered timely.

Records are also available via our online Patient Portal

If you are not already a member of our Patient Portal program, sign up today by calling our office at the extension below or by going here for more information.

Contact Us

  • Via Phone:      217-223-8400 ext. 6600
  • Via Email:       Please call us to make arrangements
  • Via Fax:          217-214-5890
  • Via Mail:         Attn: Health Information Management 
                           PO Box 7005
                           Quincy, IL 62305-7005

Our office is available from Monday-Friday, 8:00 a.m.- 5:00 p.m. Pickup locations are available at the Cashier’s office at Blessing Physician Services, Suite 106, and the main corridor outside of the Pharmacy at the Hannibal Walk-In Clinic.