Patient Records Request Form

To request copies of your medical records, please print and fill out SPH's Patient Records Request form.    

If you have any questions when completing the form, please call the Health Information Management department at 608-643-7520. 

Once you have completed this form you may:
  • Drop if off: The Patient Records Request forms may be dropped off at the Welcome desk at the hospital or any of the Sauk Prairie Healthcare Clinics.  
  • Mail it:  Patient Records Request forms may be mailed to the address listed below:

    Sauk Prairie Healthcare
    Attn: Health Information Department
    260 26th St
    Prairie du Sac, WI  53578

  • Fax it:  Patient Records Request forms may be faxed to the Health Information Department’s fax number.  608-643-7535

  • Email it:  Patient Records Request forms may be emailed to the Health Information Department at  

  • Requests are usually completed within 7-10 business days.  Requests may be completed in less than 7-10 business days if the request is for a medical need/upcoming appointment.  

Instructions on Disclosure of Health Information form

Patient Information:  Patient information  
Disclose Information to:  Mark box if patient is completing the form and wanting records sent to themselves.  If the records are to go to someone other than the patient, fill in who/where the records are to be sent to along with the address.  Can be a person or another healthcare facility 
Disclosure by:  Identify which facility you want records from (can mark more than one)
Information Disclosed:  Identify specific records you are requesting.  Be sure to note the dates of service needed/approximate dates of service are fine.