Provident Hospital

Request and Authorization to Copy Health Information

Provident Hospital of Cook County
Health Information Management Department (Medical Records)
500 East 51st St.
Chicago, IL 60615

Hours Monday – Friday, 9:00 AM – 3:00 PM
Phone (312) 572-1525 or (312) 572-1527
Fax (312) 572-1524

Cook County Health and Hospital System (CCHHS) contract with a Release of Information vendor, to process valid requests for copies of health information. In order to obtain a copy of your health information, you must complete a Release of Information Authorization Release Form. Listed below are the steps to access copies of your health information.

How to Access Your Medical Records

You may file a medical record request by downloading a Paper Medical Request Form and sending the form to:

Provident Hospital of Cook County
500 East 51st St.
Chicago, IL 60615

A copy of a valid photo ID (passport, driver’s license, state ID, or school ID) is required when submitting the Medical Record Authorization Release Form through the mail. Your health information will be mailed to the address listed on the Form.

  • There is no charge for releasing copies of health information directly to other healthcare providers.
  • Patients will be charged the following fee to access copies of their health information:
Number of Copies Medical Records Microfilm
Pages 1 -10 $5.00 flat fee $1.55 per page
Page 11+ $0.25 per page $1.55 per page

To Obtain Copies of Vital Records

Copies of birth, death, and other official records for Chicago and suburban Cook County residents can be obtained from the Cook County Clerk’s office at www.cookcountyclerk.com or (312-603-5656).

Contact Us

500 E. 51st St.
Chicago, IL 60615

Phone: (312) 572-1525 or (312) 572-1527
Fax: (312) 572-1524