To request medical records, please print, fill out, and return the HIPPA form below via email to firstname.lastname@example.org. You must also include where and how to send your records (email or mail).
Please be aware that our office hours will be severely limited. If your request is urgent, please call 262-366-3655.
A fee will be incurred for these certified medical records.
Records Request Fees
Fees depend on the number of pages requested to be sent. To avoid higher fees, we can send just your latest appointment note at no charge.
FULL MEDICAL RECORD: See Fee Schedule at bottom of page
INCLUDES: All records from every date of service since beginning care with MSWC
PROS: Provides comprehensive information about your case.
CONS: Lengthy and less likely to be fully interpreted by new care providers. Cost.
LAST MEDICAL RECORD: Free
INCLUDES: Your last visit with MSWC before closure
PROS: Succinct update about current care, clinical findings, and treatments used.
CONS: Minimal information and does not include past medical history, other conditions addressed, etc.
FULL NARRATIVE: $75
INCLUDES: A summary of your entire case, including an overview of conditions treated by MSWC. Ideally in 2 pages or less.
PROS: Comprehensive overview which will provide a great jump off point for new providers.
CONS: Cost. Estimated turnaround will be longer than other forms due to the volume expected.
PARTIAL NARRATIVE: $25
INCLUDES: Last clinical exam plus a brief summary of your current case.
PROS: A good summary for a current condition needing a transfer of care.
CONS: Cost. Estimated turnaround will be extended due to the volume expected (likely shorter than full narratives).
MEDICAL RECORD FEES
- $23.00 per records request (waived if less than 10 pages)
- Additional $1.14/page for pages 11-25
- Additional $.86/page for pages 26-50
- Additional $.56/page for pages 51-100
- Please call if over 100 pages.