Request Medical Records

To request copies of your medical records for care provided at your physician’s office, please contact your physician’s office directly.

To request copies of your medical records from one of our hospitals or outpatient centers, please print and fill out the Authorization to View/Disclose Health Information.

Once you have completed this form, you may:

• Drop it off: Authorization to View/Disclose Health Information forms are accepted during business hours. Please bring a photo ID when dropping off this form.
• Mail: Authorization forms may be mailed to the address listed below. Please include a copy of a photo ID or include a notarized signature.
• We are unable to accept authorizations via e-mail due to state and federal laws.

Requests are usually completed within one week but may be delayed if your medical record is not available. Requests may be completed in less than one week if the request is for a medical need.

In accordance with Wisconsin law, the fees charged to patients to cover the costs of copying are as follows (as of July 1, 2014):

• $1.06 per page for pages 1-25
• $0.78 per page for pages 26-50
• $0.53 per page for pages 51-100
• $0.31 per page for pages greater than 100
• $1.55 per page for microfiche or microfilm
• $10.47 for print of X-ray image
• $20.96 for retrieval of copies
• $8.38 for certification of copies
• Actual shipping costs and any applicable taxes

Upon payment, copies of medical records will be mailed or may be picked up during regular business hours. A photo ID is required when picking up copies of medical records.

10101 S. 27th Street
Franklin, WI 53130
Phone: 414-817-3965
Fax: 414-325-5066
Hours: Monday – Friday: 8 am – 4:30 pm