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Medical Records Request



Release of information and authorization to disclose - written records

Revocation of informed consent for release of patient health information

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 per page 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. 

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