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Medical Record Requests

As a patient of Lawndale Christian Health Center, you are able to receive a copy of your medical records for your personal use or for obtaining care from another healthcare provider. However, any release of your records, whether to you directly or to another person or entity, requires proper authorization to comply with our Notice of Privacy Practices, and there may be a fee to cover our costs for making the copies.

Authorization for releasing records may only be given by a patient (not the spouse), power of attorney if the patient is unable to sign (legal document must be provided), parent (if the patient is younger than age 18), legal guardian (proof of guardianship document must be provided), or representative of the estate for deceased patients (copy of the death certificate and a copy of the representative of estate documents must be provided).

If you would like to make a request for your records, please click on the following link to download a copy of the necessary form. Once completed, it can be mailed, faxed, or delivered in person to us for processing, as specified on the form. For any questions regarding medical record requests, please call our Health Information Management department directly at 872-588-3120.

Medical Record Request Form – English
Medical Record Request Form – Spanish


Medical Records Fee Schedule


Produced/Requested Medium and Cost

Format of original patient record

Cost for delivery in electronic format


       Cost for delivery in paper            


$6 flat fee

$6 flat fee

$0.05 per page


$6 flat fee

plus $0.07 per page

$6 flat fee

$0.12 per page

Immunization Records and School Physicals

No charge



1.      X-Ray records are only available via CD.
2.      Exact costs for records sent to other entities will be determined by LCHC staff and communicated to the requestor once the request is received.