Medical Records Request Form

Medical Records Request Form
By signing this form, I authorize Birchwood Family Medicine LLC to REQUEST confidential health information about me, by requesting a copy of my medical records, or a summary or narrative of my protected health information from the physician/person/facility/entity listed below.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
The information to be requsted is as follows:
Sign under each selection to also include:
Mental Health Information

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Genetic Testing Information

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HIV/AIDS Information

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Substance Abuse Diagnosis/Treatment

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Request my protected health information FROM the following physician/person/facility/entity:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax*
Please enter a valid phone number.
Signature of Patient or Personal Representative*

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Date

MonthDayYear
Date
Name

First NameLast Name
Description of Personal Representative
SEND records to:
Birchwood Family Medicine
Fax: 715-800-1972
Phone: 715-202-6782
Email: hello@birchwoodfamilymedicine.sprucecare.com
PO Box 2
101 West Loomis St., Suite A
Birchwood, WI 54817
Should be Empty: