Medical Forms

Medical Records Release Form

MPS' medical records release form is available to download. You will need Adobe Acrobat Reader installed in order to read the downloaded file.

To request medical records, this form needs to be completed, signed by the patient or legal representative, and returned to your MPS Clinic.

Notice of Privacy Practices

Memorial Physician Services is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described below.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AS WELL AS HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. EFFECTIVE 04/01/2007

If you have any questions, please contact our Privacy Office at the address or phone number at the end of this Notice.

Who will follow this Notice?

The Notice serves as a joint Notice for Memorial Health System’s (MHS) covered providers (collectively referred to herein as "we" or "our"). Because we are affiliated covered entities (ACE), as defined by the Health Insurance Portability and Accountability Act of 1996, we will follow the terms of this Notice and may share health information with each other for purposes of treatment, payment, and health-care operations as described in this Notice. The information privacy practices in this Notice will be followed by all MHS covered entities which are legally separate, independent organizations and not partners or agents of each other and:

  • All health care professionals who treat you at any of our locations.
  • All of our employees, volunteers and Medical Staff members.
  • All business associates with whom we share health information.
Where this Notice Applies

This Notice applies in the following locations:

  • Memorial Medical Center: Springfield
  • Abraham Lincoln Memorial Hospital: Lincoln
  • Taylorville Memorial Hospital: Taylorville
  • Memorial Home Services:
  • Home Health: Springfield, Taylorville, and Jacksonville
    • Durable Medical Equipment: Springfield, Lincoln, Taylorville and Jacksonville
    • Hospice: Springfield and Taylorville
    • Private Duty Nursing: Springfield and Jacksonville
  • Memorial Physician Services: Springfield, Chatham, Jacksonville, Lincoln and Petersburg
  • Mental Health Centers of Central Illinois: Springfield, Lincoln, Jacksonville and Havana
Our Pledge to You

We understand that health information about you is personal and are committed to protecting health information about you. We create a record of the care you receive to assure quality of care, for billing for care and to comply with legal requirements. This Notice applies to all of the records of your care that we maintain, whether created by facility staff or your personal doctor. Your personal doctor may have different policies regarding the doctor’s use and disclosure of your health information created in the doctor’s office. We are required by law to:

  • Keep health information about you private;
  • Give you this Notice of our legal duties and privacy practices with respect to health information about you; and
  • Follow the terms of the notice of privacy practices that is currently in effect.
Changes to this Notice

We may change this Notice at any time. Changes will apply to health information we already hold, as well as new information, after the change occurs. Before we make a significant change in our privacy practices, we will change this Notice and post the new Notice in the front entrances of our locations and on our Web site (www. memorialmedical.com).

How We May Use and Disclose Your Health Information without Your Written Authorization

The following items describe different categories of uses and disclosures of your health information that we may make without your written authorization. We have provided an example for each category, but have not listed every kind of use or disclosure within the category. We will ask for your written authorization for certain other categories of uses and disclosures of your health information, which are described below under the section entitled "Other Uses and Disclosures of Health Information."

  • For treatment, such as disclosing your health information to your doctors, nurses and others involved in your health care to provide and manage your care. We also may contact you for appointment reminders, or to tell you about or recommend possible treatment options, alternatives, health-related benefits or services that may be of interest to you.
  • For payment, such as creating bills for your care and collecting payment for your care.
  • For healthcare operations, such as administration, management, business planning and other operations of the hospital.
  • To legal representatives, such as to your parents if you are younger than 18 years old.
  • To persons involved in your care or payment for care, such as to a family member or friend identified by you, if the disclosure is related to the person’s involvement. In these situations, we will give you a chance to object to the disclosure unless you are unconscious or otherwise unable to object and we believe the disclosure is in your best interests.
  • For our patient directory, to let visitors know your location in the hospital and general condition and also to let clergy know your religious affiliation.
  • As required by law, such as where we must disclose information to comply with a federal, state or local law.
  • For public health purposes, such as to the government to report a birth or death or suspected child abuse or neglect.
  • For health oversight activities, such as to government or private agencies as part of an audit or inspection by a government agency which issues our license.
  • For organ and tissue donation, such as where a patient has died or is near death and may be a candidate for organ donation.
  • For disaster relief, such as to an organization helping with disaster relief so that your family can be told about your condition, status and location.
  • For worker’s compensation purposes, such as to comply with the Illinois worker’s compensation law or similar programs that provide benefits for work-related injuries or illness.
  • For fundraising purposes, we may use and disclose limited information about you (including your name, address, phone number and dates on which you received care from us) to our affiliated fundraising organizations;
    Memorial Medical Center Foundation
    One Memorial Plaza
    Springfield, IL 62781
    Phone: 217-788-4700
    Abraham Lincoln Healthcare Foundation
    200 Stahlhut Dr.
    Lincoln, IL 62656
    Phone: 217-732-5048
    Taylorville Memorial Hospital Foundation
    201 East Pleasant Street
    Taylorville, IL 62568
    Phone: 217-824-1651
  • For lawsuits and disputes, such as in response to a valid court order or subpoena.
  • For law enforcement, such as to respond to a law enforcement official’s request to help locate a suspect or witness or to alert law enforcement to a death that may be the result of a crime.
  • To avert a serious threat to health or safety, such as in order to prevent or lessen a serious threat to the health and safety of you, the public or another person.
  • To correctional institutions, such as to a correctional institution at which you are an inmate in order to protect your health and safety or that of others.
  • For military and veteran activities, such as disclosing health information about a member or veteran of the armed forces to appropriate military authorities.
  • For national security and intelligence activities, such as to federal officials for intelligence and other national security activities authorized by law.
  • For protective services for the president and other officials, such as to authorized federal officials for the purpose of protecting the president or foreign heads of state.
  • For disclosures about a person who has died or is near death, such as to a funeral director for funeral arrangements or a coroner or medical examiner to identify a person who has died.
Other Uses and Disclosures of Health Information
  • For any category of use or disclosure that is not described above or authorized by law, we must obtain your written authorization. If you give us your written authorization, you may revoke (cancel) it at any time by submitting a written revocation to our Privacy Office at the address below or to the department, office or other location that originally received your authorization. Your revocation will be effective except to the extent that we have already acted upon it. We will obtain your written authorization for the following categories of use and disclosure:
  • Highly Sensitive Information. Federal and state law may require us to obtain your written authorization to disclose highly sensitive health information under certain circumstances. Highly sensitive health information is health information that is: (1) in a therapist’s psychotherapy notes; (2) about mental illness or developmental disabilities; (3) in alcohol and drug abuse treatment program records; (4) in HIV/AIDS test results; (5) about genetic testing; or (6) about sexual assaults. Sometimes the law even requires us to obtain a minor patient’s authorization to disclose this highly sensitive information to a parent or guardian.
  • Research. If required by law or our committee which oversees our research activities, we will obtain your written authorization before using or disclosing your health information for research purposes.
  • Marketing. We will obtain your written authorization before using patient information about you to send you any marketing materials. However, we may provide you with marketing materials in a face-to-face encounter or give you a promotional gift of minimal value without your authorization. We may also communicate with you about products or services relating to your treatment, care settings or alternative therapies without your written authorization.
Rights Concerning Your Health Information

You have the following rights concerning your health information.

  • Looking at Records. In most cases, you may look at or get a copy of treatment or billing records. If you request copies, we may charge a fee for the cost of copying and mailing them. If we deny your request, you may submit a written request for a review of that decision.
  • Amendments. If you believe that information in a treatment or billing record is incorrect, you may request that we amend the record, by submitting a written request that states your reason for requesting the amendment. We may deny your request to amend a record if the information was not created by us, if it is not part of the health information maintained by us, or if we determine that the record is accurate. You may appeal, in writing, a decision by us not to amend a record.
  • Accounting. You may request a list called an “accounting” of certain disclosures of health information about you, other than common disclosures (such as for treatment, payment, health care operations or where authorized by you). This list may be obtained by submitting a written request, specifying the time period desired for the list, which must be less than a 6-year period and starting after April 14, 2003. You may receive the list in paper or electronic form. The first list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before you incur any costs.
  • Confidential Communications. You may request that health information about you be communicated to you in a certain way or at a certain place, such as by sending mail to your work address. We will agree to reasonable requests, but, if the request may result in our not being paid for your care, then we may require you to provide additional information about how payment will be handled.
  • Additional Limits. You may request a limit on how we use or disclose your health information for treatment, collecting payment or health care operations or to persons involved in your care. We will consider your request but are not required to accept it. We will inform you of our decision on your request. If we agree, we will comply with your request unless required by law, necessary to provide you with emergency care or authorized by you.
  • Copy of This Notice. You may get a paper copy of the current version of this Notice at any time, even if you have agreed to receive this Notice electronically. To do so you may contact the Privacy Office at the address or phone number below. A current copy of this Notice is also available on our Web site at www.memorialmedical.com.

Please submit any requests in writing to the Privacy Office or call for an address for the following locations.

Memorial Medical Center
701 North First Street
Springfield, IL 62781
Attention: Medical Records
217-788-3550

Abraham Lincoln Memorial Hospital
200 Stahlhut Dr.
Lincoln, IL 62656
Attention: Medical Records
217-732-2161 Ext. 75451

Taylorville Memorial Hospital
201 East Pleasant Street
Taylorville, IL 62568
Attention: Medical Records
217-824-1652

Memorial Home Services - Home Health/Hospice/Durable Medical Equipment and Private Duty
720 North Bond
Springfield, IL 62781
Attention: Manager Quality and Safety
217-757-7240

Memorial Physician Services:

Memorial Physician Services - Capital Healthcare

(217) 528-0307

Memorial Physician Services - Chatham
(217) 483-3487

Memorial Physician Services - Jacksonville
(217) 243- 0300

Memorial Physician Services - Koke Mill
(217) 862-0800

Memorial Physician Services - Lincoln
(217) 732-9681

Memorial Physician Services - North Dirksen
(217) 588-7400

Memorial Physician Services - Petersburg
(217) 632-7761

Memorial Physician Services - South Sixth
(217) 588-7450

Memorilal Physician Services - Vine Street

(217) 726-7300

Memorial Physician Services - Women's Healthcare
(217) 757-7932

 

Mental Health Centers of Central Illinois
Administrator, Administrative Services
710 North Eighth Street
Springfield, IL 62702
217-525-1064

Complaints

If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about your health information, you may write to or call our Privacy Office or our Compliance and Privacy AlertLine, a 24-hour phone service, at 1-800-541-9331. You may also file a written complaint with the U.S. Department of Health and Human Services – Office for Civil Rights. We honor your right to make a complaint and will not take any action against you for filing a complaint. Our Privacy Office can provide you the address of the Office of Civil Rights.