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Medical Records Information and Authorization/Consent for Release of Medical Information Form

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StethoscopeMedical Records Information

If you have any medical record questions not answered here, please call Meriter Medical Records at (608) 417-6030, Monday-Friday, 8 a.m. – 4:30 p.m. (Central Standard Time)


Q: How can I get a copy of my medical records released to a third party?
A: The appropriate form is available on the right. You will need to sign this form before we can release your medical records.
 
 
Q: Can a family member or friend sign a consent form for a copy of my medical records?
A: No one except for the person whose name appears on the medical record can sign the consent form. However, if the medical records are for a minor or an adult under the care of a legal guardian, the legal guardian may sign the consent form.


Q: How can I receive my medical records?
A: We can mail your medical records to you, or you may pick them up in Meriter Medical Records (202 S. Park Street). Medical records cannot be faxed due to lack of confidentiality.


Q: If I had a procedure done at another hospital, is that information in my medical records at Meriter?
A: Meriter only has medical records for procedures done at Meriter Hospital. To inquire about medical records on procedures done at other hospitals, you must contact each individual institution.


Q: What if I do not agree with comments made by a physician on my medical records?
A: You have the right to make an addendum to your medical record. Contact Medical Records at (608) 417-6030.


Q: Can I get a copy of my birth certificate from Meriter Medical Records?
A: Birth certificates are not kept in your medical record, even if you were born at Meriter. You will need to contact the State of Wisconsin Department of Vital Records at (608) 266-4142 for information on how to receive your birth certificate. Note that the Wisconsin Vital Records Web site also has forms you can print out to request your birth certificate.

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3/10/2008

Authorization/Consent for Release of Medical Information Form

If you wish to share your protected health information at Meriter with another party, you will need to fill out this form.

This form should also be used if you wish to share records for someone for whom you have legal authority (parent of minor, etc.). 

Download an Authorization/Consent for Release of Medical Information Form

Steps for Completing This Form

To complete the form:

  1. Click the link above and print the form.
     

  2. Fill in the form with pen, printing clearly.
     

  3. Return the form by postal mail to the address on the top of the form.

If you have any questions regarding the form or need one sent to you due to computer difficulties, call Medical Records at (608) 417-6406.

The above form is an Adobe Acrobat file. To open this file, you need to have Adobe Acrobat Reader (a free plug-in) on your computer.
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