Request Medial Records (Clinical)

Request Medial Records (Clinical)Katelyn Myhren2023-06-13T10:12:47-04:00

Name of Person Requesting*
First Last
Patient Name*
Patient First Name Patient Last Name
Patient Date of Birth*
MM slash DD slash YYYY
Email*
Phone*
Description of requested records and additional comments*
Please attach the Consent for Disclosure of Protected Health Information (PHI) here:
Max. file size: 2 GB.
This file can be found above under “How to Request a Copy of My Medical Records at WIHD”.
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