Wisconsin Medical Records Release Form 1Wisconsin Medical Records Release Form 1
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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
1. Regarding Patient

AUTHORIZATION FOR RELEASE
OF HEALTH RECORDS

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 - (i.e. Health Facility, Physician...)

Name - (i.e. Insurance Co., Lawyer, Physician, Self...)

Street Address

Street Address

City

State

Phone #

Zip Code

City

Fax #

State

Phone #

Zip Code

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
Womens Clinic Visits/Labs Only
Allergy/Immunization Records
X-ray Report/Images
Lab Results
Occupatio