To request medical records, please print, fill out, and return the HIPPA form below. You must also include where and how to send your records (email, fax, or mail).

Please return your request to our office no later than Monday, June 24, 2019.

Miller Sports & Wellness Chiropractic
3400 S 103rd St. #300
Greenfield, WI 53227
fax: 262-565-4304

Records requests sent after June 24, 2019 should be sent to QTB Limited (future custodian of records).

QTB Limited
504 Main St
Marseilles, IL 61341
fax: 815-795-2111
phone: 815-513-3654

Please allow 7-10 days for processing. If we cannot meet this deadline, a member of the billing team will contact you for an extension.

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.

0-10 pages: Free
11-25 pages: $22 + $1.12/page
26-50 pages: $50 + $0.84/page
Please call QTB Limited for more than 50 pages.