Ascension NE Wisconsin - St. Elizabeth Campus
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Under Federal and State law, a patient has a right to request a copy of his or her medical records. However, a completed written authorization is required prior to processing a request. For your convenience Ascension has made available an authorization form that may be downloaded for your personal use here. To help us process your request, please follow carefully the instructions below to ensure that the authorization is accurate and complete.
1. Patient Information
Please provide all identifying information to help us make sure we have the correct patient. If you have been seen under another name in the past, it is important that you tell us that so we can copy all available information. Additionally, it is important that we know how to contact you should we have questions.
2. Authorizes Disclosure By
Identify the organization to which you are making the request for copies. For example: Saint Michael's Hospital, Stevens Point, Wisconsin. Please note you can use this same form to request a non-Ascension healthcare provider to send records to a Ascension provider/facility.
3. Disclosure of Health Information To
Tell us who should receive the copies. Identify the individual, physician, clinic, or hospital. If the request is for personal use, indicate "self." We must have a complete and accurate name (physician or clinic) and address to be able to process the request. If you are using this form to authorize copies from another facility to be sent to a Ascension provider/facility, please indicate which Ascension organization.
4. Information to be Disclosed
Please help us identify exactly what types of reports you want copied. There are many different forms in a medical record and if we can target specifically what you want, we can avoid unnecessary copies.
5. Disclosures Requiring Special Consent
Under federal and state law, certain disclosures require a specialized consent. If you are requesting copies of medical records that may contain information pertaining to HIV/AIDS, mental/behavioral health conditions, and/or alcohol or other drug abuse treatment, you must indicate so by checking the appropriate box on the form.
6. For the Following Dates
It is extremely helpful to identify what date range you would like addressed for the purpose of this disclosure.
7. Purpose for Disclosure
Please share with us the reason for the request.
8. Your Rights
Under federal and state law, the authorization form must contain a section addressing your patient rights with regard to the form.
9. Expiration Date
Please indicate when the authorization form should expire. (This can be no longer than one year.)
10. Signature of the Patient/Patient's Legal Representative
This section must be completed before the authorization can be processed. A competent patient must sign on his or her own behalf. If the patient is incompetent, a minor, or has passed away, then the patient's legal representative may sign on his or her behalf. Please note that there are regulatory privacy protections impacting records of minors who are treated for certain conditions. Upon completing this form, please forward to the Health Information Management/Medical Record Department of the organization to which you are requesting copies. If you have any questions, please contact us for further assistance. Thank you.