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Dean Medical Records

Forms

Patient Authorization to Release Protected Heath Information (PDF)
Use this form to request copies or transfers of your medical records.

Patient Authorization to Release Protected Health Information to the Ambulatory Care Centers (PDF)
This form is pre-filled for the Ambulatory Centers.

Patient Revocation of Authorization to Disclose Protected Health Information (PDF)
Use this form to revoke (cancel) a previous medical records authorization.

Please note you need Adobe Reader to view PDF documents.

Your medical records are protected health information. To transfer medical records or request copies, requests must be submitted in writing using the "Patient Authorization to Release Protected Heath Information" form in the box to the right.

If you wish to revoke (cancel) a previously submitted authorization form, you may fill out the "Patient Revocation to Disclose Protected Health Information" form. This form is also located in the box to the right. 


Submitting Your Medical Records Request

1. Complete the form you need with the required information. Be as specific as possible.

2. You can submit your form to Dean in one of several ways:

Hand it to Us — Give your completed form to your clinic's Patient Services department.

Fax it to Us — Fax your completed form to (608) 294-6294 or (877) 469-7593, Attention: Release.

Mail it to Us — Mail your completed form to:
Dean Clinic Health Information
Attn: Release
PO Box 259840
Madison WI 53725-9840

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.


    Frequently Asked Questions

    I'm having trouble downloading and printing a form. What should I do?

    If you have trouble downloading or printing the medical records forms, you have two options:

    Call (608) 294-6244 or (877) 510-1873 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 location.

    Why should I transfer my medical records to my new provider?

    Requesting that copies of your medical records be sent to your new health care provider ensures that your new physician knows about your previous health conditions and medical treatments. Sharing this information is important for making informed decisions about your care.

    Is there a charge for transferring my medical records to another provider?

    There is no charge to transfer records or share copies of health information directly between healthcare providers.

    Can I add end-of-life care documents to my medical record?

    You may wish to keep a copy of your Power of Attorney (POA) for Health Care on file with your medical records. Submit a copy of the signed document to your health care provider and it will be added to your records.

    Can I view my medical record and will there be a charge?

    Patients can view their medical record by setting up an appointment with the Release of Information Specialist at (608) 294-6244 or (877) 510-1873. Viewing appointments are scheduled for one hour. If copies are requested, Dean Clinic may charge a reasonable fee to fulfill this request.

    Know that you can also access some portions of your medical record through MyChart. MyChart is an Internet application that allows patients to see portions of their record and communicate with their healthcare provider's office in a secure, convenient and efficient manner.

    Can I have a copy of my medical record for my personal use?

    You may request a copy of your medical records (including X-rays, test results, etc.) at any time for your personal records, using the form in the box above. If you request a copy of your medical information for your own records,you will be charged a reasonable fee for copying, preparing and mailing the information. To reduce your cost, only request specific information rather than your complete medical records.

    Can I get a copies of my children's records?

    Generally all patients 18 years of age and older must sign for release of their own health information. Patients less than 18 years of age must sign for release of their health information in the following cases:

    Alcohol and Drug Abuse Treatment — Age 12 and older.

    Mental Health Treatment — Age 14 or older may consent to release of records without parental consent (parents also retain the right to access this information).

    HIV Test Results — Age 14 or older and emancipated minors who are married or in the military.

    Who can I contact if I still have questions?

    If you have questions about copying or transferring your medical records, please call Dean Health Information at (608) 294-6244 or (877) 510-1873 and a staff person will assist you with your questions.

    MyChart Offers Easy Access to Your Medical Record

    With MyChart, you have online access to your appointments, medical record, lab results and other information. Learn more.

    Transferring to Dean Clinic Pharmacy

    If you need to transfer your records or prescriptions to Dean Clinic Pharmacy, simply call the Dean Clinic Pharmacy location nearest you and we'll take care of the details.

    If you need a copy of your Dean Clinic Pharmacy records, submit a completed Authorization to Release Pharmacy Records Form to the following address:

    Dean Clinic Pharmacy
    Insurance Department
    1808 W. Beltline Highway
    Madison, WI 53713