Please print and complete the Authorization for Release of Medical Information form if you wish to share records and/or receive detailed voice messages related to your health information. The form should also be used if you wish to share records with someone for whom you have legal authority (parent of minor, etc.).
Helpful Tips | Completing the Authorization Form:
- In number 2 on the authorization form, you will put "Meriter Hospital or Meriter Clinics." You are authorizing Meriter to release your records.
- In number 3 on the authorization form, you will put where you want your records sent.
- Please make sure all information is complete and legible; this will eliminate delays in your request.
Authorization for Release of Medical Information
Frequently Asked Questions
Q: Will I be charged for a copy of my medical records?
A: Meriter contracts with a third party company. The charges are listed in the Authorization/Consent for Release of Medical Information form that's below.
Q. How can I transfer my medical information to Meriter?
A. There are two options for transfering your medical information to Meriter:
- If you are transferring your care to a Meriter clinic, please contact your current provider to fill out an authorization form. After you fill out the form, please send it back to your current clinic and someone at that clinic will forward the form on to your new provvider at Meriter.
- If you are transferring your care to a Meriter clinic, you can fill out the Authorization/Consent for Release of Medical Information from Meriter Hospital and Clinics form that's above to request medical records from your current provider.
**For question number #2 on the form, please provide information about your current primary care physician and clinic.
**For question #3 on the form, please provide information about your new primary care physician at a UnityPoint Health – Meriter clinic.
Q: How long does it take to process my request?
A: Approximately 7-10 business days.
Q: Can a family member or friend sign a consent form for a copy of my medical records?
A: No one except for the person whose name appears on the medical record can sign the consent form. However, if the medical records are for a minor or an adult under the care of a legal guardian, the legal guardian may sign the consent form. If you are the legal guardian, we will need a copy of the guardianship papers along with the authorization form. If you are the POA, we will need a copy of the POA and activation form (certificate of incapacity statement) along with the authorization form. This will allow us to process your request in a timely manner.
Q: How can I receive my medical records?
A: We can mail your medical records to you, or you may pick them up at Meriter's Health Information Management department. Please call (608) 417-6406 to schedule an appointment.
Q: If I had a procedure performed at another hospital, is that information in my medical records at Meriter?
A: Meriter only has medical records for procedures performed at Meriter hospital and clinics.
Q: What if I do not agree with comments made by a physician on my medical records?
A: You have the right to make an addendum to your medical record. If you would like to do so, please complete and mail the form that's below to the Meriter Department of Health Information Management. Contact the Meriter Department of Health Information Management at (608) 417-6406 if you have any questions.
Q: Can I get a copy of my birth certificate from Meriter?
A: You need to contact the State of Wisconsin Department of Vital Records at (608) 266-1371 for information on how to receive your birth certificate. The Wisconsin Vital Records Web site also has forms you can print out to request your birth certificate.