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Medical Records Request

How to request your medical records

To request a copy of your medical records, you must print and fill out the ProHealth Care Authorization to Release Protected Health Information form.

Once you have completed this form, you can:

  • Personally deliver: ProHealth Care Authorization to Release Medical Record forms are accepted during business hours. Please bring a photo ID when you are dropping off this form. The drop-off location is listed below.
  • Mail: Please send your completed form to the address below:

Health Information Management – Release of Information
N17 W24100 Riverwood Dr., Suite 200
Waukesha, WI 53188

  • Fax: Fax your completed form to 262-928-5756.

We are unable to accept authorizations via e-mail due to state and federal laws.

Requests are usually completed within one week but may be delayed if your medical records are not available or complete. Request may be completed in less than one week if the request is for medical needs. 

Authorization forms

You need Adobe Acrobat Reader to view PDFs. Download a free copy.

In accordance with Wisconsin law, the fees charged to patients to cover the cost of copying are as follows:

  • $1.04 per page for the first 25 pages (hard copy or imaged)
  • $0.77 per page for pages 26 – 50 pages (hard copy or imaged)
  • $0.52 per page for pages 51 – 100 (hard copy or imaged)
  • $0.31 per page for 101 and above (hard copy or imaged)
  • $1.55 per microfilm/microfiche pages
  • $10.32 per image for print of an X-ray, and
  • Actual postage, and
  • Applicable sales tax

Upon payment, copies of medical records will be mailed or may be picked up during regular business hours. A photo ID is required when picking up copies of medical record.

Making an appointment to view your medical records

To arrange an appointment to view your medical records, call the Health Information Coordinator at 262-696-5856. Appointments are scheduled as soon as possible, but may be delayed if your record is not available.

For more information