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Medical Records / Submitting a Request
Forms
Patient Authorization to Release
Protected Heath Information Form (PDF)
Use this form to request copies or transfers of your medical
records.
Patient Revocation of
Authorization to Disclose Protected Health
Information Form (PDF)
Use this form to revoke (cancel) a previous medical records authorization.
Trouble Downloading or Printing a Form?
You need Adobe
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to
view PDF documents. If you have trouble downloading or printing
the medical records forms:
- Call (608) 252-8275 to request the appropriate medical records form be mailed or faxed to you. Please provide your name, mailing address, or your fax number with area code if leaving a message.
- OR request a medical records form when you are visiting your Dean clinic.
Submitting Your Medical Records Request
1. Complete the form with the required information. Be as specific as possible.
2. Either:
HAND IN your completed form to your clinic's Medical Records department.
OR FAX the completed form to (608) 252-8285, Attention: IOD Inc.
OR MAIL to:
Dean Medical Records
Attention: IOD Inc.
1313 Fish Hatchery Rd
Madison WI 53715
3. Copies of your records will be transferred to the requested destination. Your request may take several weeks to process, depending on the number of records that are copied and transferred.
Still Have Questions?
If you have questions about copying or transferring
your medical records, please call IOD Inc., Dean's medical records
copying and transferring service at (608) 252-8275 and a staff
person will assist
you with your questions.
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