Patient Records Request Form

Authorization for Disclosure of Health Information Form

Please print and have the patient fill out an Authorization for Disclosure of Health Information 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: Authorization for Disclosure of Health Information forms may be dropped off at the Welcome desk at the hospital, at the Wellspring Campus Rehab front desk, or any of the Sauk Prairie Healthcare Clinics.
  • Mail it:  Authorization for Disclosure of Health Information 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:  Authorization for Disclosure of Health Information forms may be faxed to the Health Information Department’s fax number: 608-643-7535

  • Email it:  Authorization for Disclosure of Health Information forms may be emailed to the Health Information Department at Myhealth.Support@saukprairiehealthcare.org.  

  • 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 how to complete the Patient Records Request

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 wanted -Make sure to note the dates of service needed/Approximate dates of service are fine.  

Expiration:  Fill in date/event.  If nothing is filled in, the release if good for one time.  

Signature of Patient/Legal Rep:  have patient or legal representative sign the release form. 

Signature of Patient/Legal Rep:  have patient or legal representative sign the release form.  This is for HIV/AIDS, Mental/Behavioral Health or Drug/Alcohol Abuse