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Use this form to request a copy of your health records from Elemental Care - Health & Wellness Center, LLC, or to have them sent to another person or organization. Our office will respond within 30 days.

You may also request records in writing by mail to 20660 Caton Farm Road, Unit F, Crest Hill, IL 60403, by fax to 815-714-5369, or in person at our office. Questions? Call us at 815-714-5430.

Psychotherapy notes and substance use disorder counseling notes are not included in a records request.

Patient information

Patient date of birth
Month
Day
Year

Who is submitting this request

I am submitting this request as
I am the patient
I am the patient's personal representative

Records requested

Which records do you need?
Complete record
Specific records
Dates of service
All dates
A specific date range

Delivery

How would you like to receive your records?
Patient portal
Secure encrypted email
Standard (unencrypted) email
Mail to my address
Pick up in office
Who should receive the records?
Send to me
Send to another person or organization

Identity verification

Driver's license, state ID, or passport

Acknowledgments

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Date signed
Month
Day
Year
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