Release of Information

Filling out your Release of Information Form:

Download Release of Information Form

In order to expedite the process faster, please be sure the following areas are completed:

  • Specify the information you are requesting by check box
  • Specify the date range
  • Patient name and date of birth are complete and correct.
  • Name and address are clearly printed (of person/agency requesting the information)
  • If the patient is 12 years of age or older, his/her signature and date is present.
    (WITHOUT THIS NO INFORMATION CAN BE RELEASED)
  • If the patient is under the age of 12, the parent/guardian signature and date is present.

We will be processing your request upon return of the completed authorization form. Please allow up to 14 days for processing. Any missing components will cause further delay. If you are in need of the information urgently, please document the date you need the information.

Please fax/mail the completed authorization form to:

Lincoln Prairie Behavioral Health Center
Attn: Health Information Mgmt Dept.
5230 S. Sixth Street Road
Springfield, IL 62703
Phone: (217) 585-1180
Fax: (217) 585-4746

HIPAA Notice of Privacy Practices | Privacy Policy | Nondiscrimination Notice | Language Assistance