Medical Records Request

Release of Information:

To obtain a copy of your medical records, print and complete the Authorization To Release Protected Health Information form. This form needs to be completed by the patient or their legal representative in order for us to release medical record information to our patients or to another party. Please fax the completed form to the Release of Information Specialist at 715-463-2753. (Note: incomplete forms will not be able to be processed.) To contact the Release of Information Specialist please call 715-463-5353 extension 7526.

For release of radiology images only, please fax the completed Authorization To Release Protected Health Information form to the Radiology Department at 715-463-7347.

Receiving Your Requested Records

Processing medical record requests may take up to seven (7) business days from date of receipt. Records will be released and delivered in the method indicated on the authorization form. Occasionally delays may occur and we will attempt to contact you if extra time is needed to process your request. Please bring a photo ID if you choose to pick up the medical records in person. (Note: It is Burnett Medical Center policy NOT to fax medical records except to another healthcare facility.)

How much will it cost?


The cost is dependent on the type of use.
There is no charge for information to be sent from our facility directly to another healthcare facility or provider (continued medical care).
Patients requesting electronic copies of medical records will be charged a cost-based fee. For detailed information please contact the Release of Information Specialist at 715-463-5353.
Patients requesting paper copies of their medical records for their own personal use will be charged a fee for copies in accordance with the Wisconsin fee schedule:

Schedule of Health Care Provider Records Fees - July 1, 2017 - June 30, 2018
Paper Copies (per page):
First 25 pages: $1.10
Pages 26 to 50: $0.82
Pages 51 to 100: $0.54
Pages 101 and above: $0.32

Print of an X-ray: $10.84 (per image)

If the requestor is not the patient or a person authorized by the patient:
Certification of Copies: $8.69
Retrieval Fee: $21.73
Actual Shipping Costs and Any Applicable Taxes

Wisconsin Immunization Registry

You may use the Wisconsin Immunization Registry (WIR) to check the status of your own or family member's immunization status. Go to: http://www.dhs.wisconsin.gov/immunization/wir.htm
Public Immunization Records Access
Enter name and social security number
Search

Medical Records Inquiries

The Health Information Department is committed to ensuring your medical records are complete and accurate. If you have any questions or concerns regarding your medical records please contact:

          Tamra White, HIM Director, at 715-463-7232
          E-mail: twhite@burnettmedicalcenter.com, or

          Amanda Manning, HIM Manager, at 715-463-7385
          E-mail: amanning@burnettmedicalcenter.com.