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Release of Information

Instructions For Release of Information

Please complete the Authorization for Release of Patient-Identifiable Health Information form with all of the information including the complete mailing address, phone and fax number to where you would like your records sent.

Please check the appropriate boxes as to which records you would like included. These records will not be released if the boxes are not checked.

If you have an upcoming appointment, please note this on your release. I will make every effort to get your records to their destination on time.

Please sign, date and return the Authorization for Release of Patient-Identifiable Health Information form to me at: 1111 Delafield Street, Suite 311, Waukesha, WI 53188 Or by fax (262) 650-3856
If you have any questions, please feel free to contact me at (262) 544-4411 ext 105.

Thank you,
Kelly Jacobson
Health Information Manager
Moreland OB-GYN Associates, S.C.

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