Request medical records information
Valid and complete medical record requests can take up to 30 days to process, and all requests are handled in the order in which they are received. To avoid delays, we ask that requests be submitted only one time and recommend leaving one voicemail to check status, to avoid processing delays. To ensure all required elements are included, please use the form below.
Clients who are currently open to services can request records directly from their counselor or clinician during their visit and be provided with some records at their appointment. Once closed to services, records can be requested electronically, via mail, or in person at any Rosecrance location.
If you are a provider, attorney, or other entity requesting records, you may use the same form for requesting records and submit it via fax, mail, or email.
Thank you for your patience,
Rosecrance Behavioral Health
Medical Records Department
Medical record forms
Authorization to Disclose Medical Records
Completion of this form is used only to request medical records. Once completed, it authorizes the release of records based on the details provided.
Illinois Petitioner Treatment Verification
The Illinois Petitioner Treatment Verification is part of the Illinois Secretary of State’s Department of Administrative Hearings, and is filled out for providers once drivers within the state have completed treatment.
Submit your form
Each form should be submitted to the Rosecrance entity responsible for the client service. Forms may be submitted by mail, fax, or email. For questions, please call or email the correct location.
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Mailing address
Rosecrance Behavioral Health
Attn: Medical Records Department
1021 N. Mulford Road
Rockford, IL 61107Call
(815) 720-4940
Fax
(815) 720-5089
Email
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Mailing address
Rosecrance Jackson Centers
Attn: Medical Records Department
800 5th Street
Sioux City, IA 51101Call
(712) 234-2324
Fax
(712) 258-5679
Email