Medical Records Request Form

Medical Records Request Form

Submit this form to request copies of your medical records or send them to another provider
Patient Full Legal Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*
Please enter a valid phone number.
Email Address
example@example.com
Date of Birth*

MonthDayYear
Date
Records Release Information
Please release my records to: (Name of Organization or Business)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records I would like to release: (check all that apply)

Physician NotesLaboratory Reports including Pathology ReportsX-Ray/Radiology/ MRI ReportsAll Diagnostic Tests, including EMG & Bone DensityOperative ReportsTherapy NotesBilling RecordsFilms & CDsOther
Year of Service and/or Part of Body:
Purpose for Requesting Release:

Follow-Up Medical Care/ 2nd OpinionLegalPersonalInsuranceWorker's CompensationDisability/FMLAOther
Release By:

MailEmailLocation Pickup: MukwonagoLocation Pickup: BrookfieldLocation Pickup: Pewaukee
Upload Medical Records Form or Any Documentation

Medical Records Form here: https://orthowisconsin.com/wp-content/uploads/2025/05/AuthForm_PreFill_Blank.pdf
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Addition Comments
Your Rights with Respect to this Authorization:
I understand that I have the right to inspect and receive a copy of the health information I have authorized to be disclosed by this authorization form. I understand that if I agree to sign this authorization, I may receive a copy. I understand that I am under no obligation to sign this form and that Orthopaedic Associates of Wisconsin may not condition treatment or payment of claims. I understand that I have the right to revoke this authorization at any time by providing written notice to Orthopaedic Associates of Wisconsin. I understand that my revocation will not be effective as to uses and/or disclosures already made in reliance upon this authorization. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by Federal privacy standards. Copy of Facsimile (FAX) Valid as an Original.
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Medical Records Request Form

Records Release Information