Request Your Riverside Medical Records

Take charge of your health information in the way that works best for you.

Request Records with MyChart

Prefer Paper? Download & Submit the Consent Form

Can’t use MyChart? Download our fillable PDF, type in the fields, then sign.

Download Fillable Consent Form

How to Complete Consent Form

Section A:

Enter the name, birth date, and last four digits of the social security number of the patient for whom you are requesting medical records to ensure that we search for the correct patient.

Section B:

Enter the name of the person who is authorizing the release of these records (the person who will be signing the consent form).

Section C:

Enter complete mailing information for the individual to whom medical record copies should be sent.

Section D:

Enter the date range for which you request medical records on the line marked “D”; Riverside Medical Center follows a ten-year retention schedule for medical records. Records from CY 2007 to the present should be available.

Section E:

Mark the box(es) of the document(s) you are requesting in; if the selections listed do not meet your needs, mark “Other” and clearly describe the documents you are seeking.

Section F:

Enter the reason you’re requesting medical records.

Section G:

Sign and date the form

Section H:

If you are not the patient, complete this section.

Example of form showing sections A through H

Where to Send Your Form

By Mail

Riverside Medical Center
Health Information Management
Attn: Release of Information Area
350 N. Wall Street
Kankakee, IL 60901

By Email

Email completed form to:
ROI@rhc.net

By Fax

Fax completed form to:
(815) 935-7863

Copy Fees & Shipping Information

Requestor Type	Handling Fee	Pages 1-25 (per page)	Pages 26-50 (per page)	Pages 51+ (per page)	Digital Copy (CD)
Copy Fees for Patients	$0	$0.75	$0.50	$0.25	50% of paper fee
Copy Fees for Attorneys / Insurance / Other	$33.60	$1.26	$0.84	$0.42	50% of paper fee
No fee is charged when records are sent directly to another healthcare provider for continuity of care. *Postage is billed at the actual shipping cost. Payment is due at pick-up; for mailed orders, copies totaling $10 or less are sent with a bill, while orders over $10 are shipped after payment of an invoice sent in advance.

Requestor Type

Handling Fee

Pages 1-25
(per page)

Pages 26-50
(per page)

Pages 51+
(per page)

Digital Copy
(CD)

Copy Fees for Patients

$0.75

$0.50

$0.25

50% of paper fee

Copy Fees for Attorneys / Insurance / Other

$33.60

$1.26

$0.84

$0.42

50% of paper fee

*No fee is charged when records are sent directly to another healthcare provider for continuity of care.

**Postage is billed at the actual shipping cost. Payment is due at pick-up; for mailed orders, copies totaling $10 or less are sent with a bill, while orders over $10 are shipped after payment of an invoice sent in advance.

How to Amend Your Medical Record

If you believe the information in your medical record is incorrect or outdated, you can submit a written request to amend your Protected Health Information (PHI).

Please download and complete the Amendment Request Form for Medical Records and follow the instructions included in the document. Once completed, return the form and supporting documentation to the Chart Correction Unit via mail, fax, or email as indicated.

Questions? We’re Here to Help!

Please contact our Release of Information Center if you have any questions or would like assistance submitting your request.
Call Us: (815) 935-7256 ext. 38304