Request For Medical Records

How Do I Request a Copy of My Hospital Medical Record?

To request a copy of your medical records at Beloit Health System or NorthPointe, complete an Authorization for Release of Patient Heath Information form, and submit it to the Health Information Management Department at the Beloit Hospital.

Authorization for Release of Patient Heath Information Hospital Form
Authorization for Release of Patient Health Information Hospital Spanish Form

Counseling Care Center Informed Consent for Disclosure of Patient Health Care Information Form

Counseling Care Center Informed Consent for Disclosure of Patient Health Care Information Form - Spanish

You may submit the request in person from 8:00am to 4:30pm or by mail to:

Beloit Hospital
Health Information Management
1969 West Hart Road
Beloit, WI 53511-2230
Attn: Release of Information

If you are hospitalized, you may submit the form to the Health Information Management Department, located on the first floor, upon discharge from the hospital.

How do I request a copy of my clinic medical record?
To request a copy of your clinic medical records, complete an Authorization for Release of Patient Heath Information form, and submit it to the Health Information Management Department at the clinic.

Beloit Clinic
Health Information Management
1905 E. Huebbe Pkwy
Beloit, WI 53511
Attn: Release of Information

Who Is Authorized to Sign for the Release of My Medical Records?

• The following people are authorized to sign for release of health information:
• The patient, if 18 years of age or over (not a spouse or a parent of a patient over 18)
• The parent or legal guardian, if the patient is younger than 18 years of age, with the exception noted here:
• The patient if over 12 years of age requesting a mental health record release, or records Containing HIV/AIDS, drug and alcohol, sexually transmitted disease, pregnancy and /or Birth control information (According to state law, a child 12 or over must authorize release of this highly confidential information).
• A guardian, if the patient is legally judged incompetent
• Emancipated minor (the minor is legally married, is a parent, is pregnant, or has been legally emancipated by the court)

How Much Does It Cost to Obtain Copies of My Medical Records?

• There is no charge for releasing copies of health information directly to another health care provider when records are sent directly to the healthcare provider's address.
• If medical records are not being sent directly to another health care provider there is a fee. Please contact us at 608.364.5128 to determine the fee amount.
• To reduce the cost, patients should consider requesting specific information rather than a complete record.

How Long Will It Take to Receive Copies of My Medical Record?

• Once the request is received in the Health Information Management Department the average turnaround time is up to two weeks. In some cases your request may take longer, we will contact you if this should be the case for your request.
• You will receive an invoice of your copying charges with your medical records. Payment methods are listed on the invoice.

Guidelines for Completing the Authorization Form.

Patient information

• Patient's full name
• Patient's date of birth
• Address
• City/State/Zip

To disclose to:

• Enter the name of the person/institution to which records are to be released.
• Enter the name /institution and complete address of where you wish your records to be sent.

Service dates to be released:

• Specify the date(s) of treatment for which you are requesting records. Documents will be copied for the dates of treatment you specify.

Specific information requested:

• Select individual reports or select other and list specific records to be released.

Purpose of disclosure:

• Select or specify the reason for releasing medical records.

Authorization expiration:

• Specify the date on which the authorization will expire. If left blank the authorization will expire 6 months from the date of signature.

Signature of Patient:

• Patient must sign and date the patient authorization for it to be valid.
• If someone other than the patient signs the authorization they must include relationship to patient (guardian, POA, etc.).
• Valid picture I.D. is required to release copies of health information.

Submit in Person:

You may submit the request in person from 8:00am to 4:30pm.

Mail To: