medical records request

To authorize the release of records to someone other than yourself or your personal representative:

  1. Fill out this Authorization To Release Protected Health Information form.
  2. Once completed, please send it to the Release of Information Specialist via email roi@burnettmedicalcenter.com or fax 715-463-2753. 

 

To authorize the release of radiology images only:

  1. Fill out this Authorization To Release Protected Health Information form.
  2. Once completed, please send it to the BMC Diagnostic Imaging department via email radiology@burnettmedicalcenter.com or fax 715-463-7347. If you have questions, please contact Radiology at 715-463-7292. 

 

Upon receipt, we will process your medical record request and send it as indicated in the authorization form. This may take up to seven business days. A member of our team will 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. 

 

If you are requesting electronic or paper copies for personal use, there will be a fee in accordance with the Wisconsin fee schedule. For detailed information please contact the Release of Information Specialist at our facility in Grantsburg, WI at 715-463-7240 or roi@burnettmedicalcenter.com.