Free Medical Release Form 21Free Medical Release Form 21Free Medical Release Form 21
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UNIVERSITY OF WISCONSIN-MADISON
UNIVERSITY HEALTH SERVICES
HIM (Medical Records)
333 East Campus Mall, Rm 8102
#8104
Madison, WI 53715-1381
Phone: (608) 262-1676 Fax: (608) 262-9160
AUTHORIZATION FOR RELEASE
OF HEALTH RECORDS
1. Regarding Patient COMPLETE IN FULL (See reverse side for further
information)
Name - Last, First, MI
Street Address Telephone #
City State Zip Code
UW ID#
Birthdate
2. Records Released From____________________________________________
3. Records Released To______________________________________________
Name Name Street Address
Street Address
City State Zip Code
City State Zip Code
Phone #
Fax #
Phone #
Fax #
Records are needed for an appt on ____________/
Records needed to schedule appt.
P/U Copies--call me when ready
4. INFORMATION TO BE RELEASED: (Check all applicable categories)
Complete Copy of Clinical Records
Mental Health Summary Letter
Psychiatry Transfer of Care
Womens Clinic Visits/Labs Only
Complete Copy of MH Records
Routine – Compl