MEDICAL RECORDS RELEASE FORM - PRACTICE CLOSURE

PLEASE NOTE: Whole Child Pediatrics will permanently close on April 30, 2026.

All records requests must be submitted and received no later than April 30, 2026. After that date, records requests should be directed to the Records Custodian:

Marc Drummond
520 E Kendall Dr. Unit A, Yorkville IL 60560
medicalrecords@wholechildonline.com

Your request will be sent to our office. If you have questions or problems, please email the medical records office at medicalrecords@wholechildonline.com
THE FOLLOWING STEPS OCCUR ONCE THE ROI PROCESS IS COMPLETE:

* The medical records requestor is notified via email of any missing or incomplete items when the request does not meet all HIPAA and/or state requirements.

* Medical records are distributed by download in a standard PDF format using our secure delivery service after all compliance and payment requirements have been met.

* By providing the e-mail address of where you would like your medical records sent, we can send a link so they are able to be downloaded.
By signing this form, I authorize Whole Child Pediatrics (or after April 30, 2026, its designated Records
Custodian) to release my or my child’s confidential health information. A copy of the medical record(s), or a summary or narrative of my protected health information will be released to the physician/person/facility/entity listed below.