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1. Who is authorized to sign for the release of information to obtain a copy of the medical record?

The following individuals may sign the authorization for release of medical information:

• The patient
• The parent or legal guardian
• If patient is deceased, the next of kin may sign for the patient with identification. A copy of the death certificate along with either court documents stating that they are the executor of the estate or they must complete an authorized relative certification.
• If patient is unable to sign for their records, the person requesting the records must provide a healthcare power of attorney. A spouse or domestic partner may not request medical records without the patient's consent.
• All requests for behavioral health records require specific authorization and a witness signature. If patient is under 12 years of age, a parent or legal guardian can sign for the release of medical records. If patient is between 12 years of age or older, the patient must sign for their own records.

2. How much does it cost to obtain a copy of my medical record?

• If you are requesting the records for personal use, the fees are as follows:
Basic Fee: Free of charge. NOTE: Records must be mailed directly to the patient

• If you are requesting the records to be transferred to another healthcare facility, the fees are as follows: Free of charge
NOTE: You must provide the full address of the healthcare facility, including the city, state and zip code.

• If you need a copy of your medical records for your insurance company, attorney or any other 3rd party or agent, the fees are as follows:
Basic Fee: $26.77 and $1.00 per page for the first 25 pages, $0.67 per page for pages 26-50, and $0.33 per page for pages 51+, plus shipping & handling (if applicable).

3. When will I receive a copy of my medical record?

The Medical Records Department receives a large number of requests, and many of the records requested are very complicated. Your request will be processed within seven business days. If you need your records more urgently, please call the Medical Records Department at 847-377-8592.

4. Who should I contact if I have questions?

If you have any questions, please call the Medical Records Department at 847-377-8592.

5. How do I file a complaint regarding the privacy of my health information?

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services, Office of Civil Rights. To file a complaint with the Lake County Health Department/Community Health Center, contact the PRIVACY OFFICER at the address listed below:

Lake County Health Department and Community Health Center

Privacy Officer
3010 Grand Ave.
Waukegan, IL 60085
847-377-8592, Option 3

Office of Civil Rights
U.S. Department of Health and Human Services

233 N. Michigan Ave., Suite 240
Chicago, IL. 60601
Phone: (312) 886-2359; (312) 353-5693 (TDD)
http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html

All complaints must be submitted in writing and addressed to the PRIVACY OFFICER. We support your right to protect the privacy of your medical information. We will not retaliate in any way or refuse services if you choose to file a complaint with us or with the U. S. Department of Health and Human Services, Office of Civil Rights.