GENERAL GUIDELINES
As noted in our generic instructions for ordering neurological records from any institution, the brain bank:
- now requires that records be at the brain bank prior to the passing of the intended brain donor
- neurological records ONLY are needed. No primary care physician records or hospice records. In the cases of Parkinson’s Disease, only the most recent 6-8 years of records are needed.
- it is always easiest to download neurological records via the online patient portal. If you don’t have access to the online patient portal, records must be ordered from the medical records office or clinic. Records can be sent from medical records offices or clinics directly to the brain bank. One advantage of this approach is that there may be no fee to the family. One disadvantage of this approach is that the family has no real way to confirm that records have been sent.
- ideally, records should be sent to the brain bank by email or posted to the cloud for the brain bank to download. Second choice is by fax. Third choice is by mail with tracking. Last choice is by mail with no tracking.
- ordering records and following up with the medical records offices or clinics is the family’s responsibility
Source: JDG/Pixabay
NORTHWESTERN MEDICINE INFORMATION
These suggestions are derived from speaking with staff from the medical records office and viewing helpful webpages, including:
Request Medical Records or Images | Northwestern Medicine
There are two main ways to request medical records from Northwestern Medicine.
1. Request medical records online through Northwestern Medicine Online Tool.
The Northwestern Medicine online tool allows you to request your health records. The online tool verifies your identity using a valid photo ID, such as your driver’s license. You do not need a MyNM patient portal account for this option.
Please request neurologically-related records to be submitted to Mayo Clinic by:
- Secure email to Dennis Dickson, MD, ℅ the Brain Bank Coordinator, Rachel LaPaille-Harwood, at [email protected]
- Fax to 904-953-7117 (Attn: Dennis Dickson, MD)
- US Mail to Dennis Dickson, MD, Mayo Clinic Jacksonville, Birdsall 310, 4500 San Pablo Road, Jacksonville, FL 32224-1865 (phone 904-953-2439)
2. Request medical records directly from Northwestern Medicine by completing a hard-copy Authorization Form.
Northwestern offers a paper authorization form. Download the Authorization for Release of Medical Information Form. The form is available in English or Spanish.
-> Provide Details: Be sure to provide as much detail as possible when completing the form, including specific dates of service and the names of providers. This will help expedite your request.
-> Release Information From: Check locations where the intended donor has received care/services. Check all that apply.
-> Purpose of Information Release: The form asks for a reason for the release of information. Please check the box next to “Other (specify)” and write in or type either “medical research,” “clinical-pathological correlation,” or “brain bank research.”
-> For Dates of Service (From/To): If you do not recall specific dates, use a broad date range to capture all the visits/appointments. Be sure to include an actual ending date. Please note that if no dates are listed, records will include only the past 24 months.
-> Medical Records to be Released: Beneath the date range, check the following boxes as applicable:
- “Emergency Room Visit” – if the patient was seen at the ER for neurological reasons
- “Hospital Stay” – if the hospitalization was for neurological reasons
- Do not check outpatient surgery procedure box
- “Clinic, Office Visit or Immediate Care” – please write or type in the name of the specialist seen for neurological symptoms
- “Test Results/Reports Only” – check the box next to radiology also
- “Other” – please specify the name of any additional specialists the patient has seen for neurological symptoms
(Note: Mayo will want any reports from scans, images, or testing but does not need the actual images themselves.)
-> Method of Delivery: Check the box for “E-mail to” and provide email address – [email protected]
-> You can skip the section titled “Medical Images to Be Released.” Mayo Clinic does not need the actual images, only the reports, which are covered by the “Medical Records to be Released” section.
-> Send Information to: Dennis Dickson, MD, Mayo Clinic Jacksonville, Birdsall 310, 4500 San Pablo Road, Jacksonville, FL 32224-1865 (phone 904-953-2439, fax 904-953-7117)
-> Signatures: The authorization form must be completed thoroughly, dated, and signed. It is best if the intended donor signs the form. If the intended donor is signing the form, return it via email, fax or US mail along with a valid ID document, such as a legible copy of a driver’s license or state ID card.
If the intended donor is not able to sign, the medical power-of-attorney should sign his/her name. When you email, fax or mail the completed authorization form, include the medical power-of-attorney document and a photograph of the medical power-of-attorney’s government-issued ID.
Submit the completed form to Northwestern Medicine via:
- Email [email protected]
- Fax 312-926-3093
- Mail (Northwestern Medicine, HIM – Release of Information Department, Attn.: Medical Records, 25 North Winfield Road, Winfield, IL 60190)
Your request will be processed within thirty days. We suggest a follow-up call to the Northwestern Medicine Health Information Management office a week after submitting the authorization form. Inquire when the records were sent (or will be sent) and confirm the delivery method. Make a note of the date and method of delivery. The Health Information Management office can be reached at 877-9-RECORD (877-973-2673).