Medical Records Request


Release of information and authorization to disclose form

Revocation of informed consent for release of patient health information form

Identity verification form

BayCare Clinic is a partnership of specialty physicians that serves communities in northeast Wisconsin and Michigan’s Upper Peninsula. Many of our physicians have clinic offices, but also see patients at area hospitals and surgery centers for procedures. Medical records related to care provided in a hospital or surgery center are not BayCare’s records, but rather the records of the hospital or health system where the services are provided – therefore, they are maintained and can only be obtained via request from the facility where those services were provided.


If you need a release of medical records from a BayCare Clinic provider, please use the above form. Once this form is completed, please send it to:


BayCare Clinic

Attn. Release of Information Department

PO Box 28900

Green Bay, WI 54324-0900

Or fax to: 920-544-5586

There is a fee associated with the release of medical records. You will be contacted by BayCare Clinic regarding the charges that will be incurred before the records are released. If you have any questions, please call 920-544-5414.