Medical Records Request

Request your medical records

• Release of information and authorization to disclose form
• Revocation of informed consent for release of patient health information form
• Identity verification form
• Divulgación de información y autorización para divulgar

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.

Where do I send my medical records request?

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:

Is there a fee associated with requesting medical records?

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.

Additional questions?

If you have any questions, please call 920-544-5414.