Request medical records information
To submit a request for a Rosecrance client medical record, find the forms you need, download and fill them out, and submit them to the location associated with your treatment.
Medical record forms
Authorization to Release Information
The Authorization to Release Information disclosure allows the sharing of treatment information to coordinate care.
Request for Access to Inspect or Copy Client Record
The Request for Access to Inspect or Copy Client Record form must be filled out when client information is being requested.
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
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Mailing address
Connections Counseling
5005 University Avenue, Suite 100
Madison, WI 53705Call
(608) 233-2100 ext 0
Fax
(608) 233-2101
Email
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Mailing address
Aspen Counseling
8616 Northern Avenue,
Rockford, IL 61107Call
(815) 399-9700
Fax
(815)-720-5089
Email