There may come a time when you are required to see a provider in a medical facility other than a Prevea Health Center. When this happens, it's important to supply the new provider with access to your medical records. If you choose, you may pick up your records and take them to your new appointment, or you can have Prevea transfer them for you. In either case, accuracy and protecting your privacy are assured.
If you want us to release your information to you or to send it to another medical facility, please read and follow the steps below.
Click on the Medical Records Release form below. Once you can view the document, print a copy, then complete, sign, and mail or fax it to the Prevea Medical Records Department:
Attn: Records Release
PO Box 19070
Green Bay, WI 54307
Fax: (920) 496-4737
If you are completing and signing the form for another person, you need to state your relationship to the person/patient (e.g. mother of a minor). Be sure to spell the facility name that you want the records mailed to accurately. This helps us to send the information to the right place. We require at least two business days to complete the release process.
We do not send your entire medical record to other facilities; we send copies. Should you want to return to our providers in the future, your medical record will be here. The state of Wisconsin requires us to maintain your chart for at least seven years beyond the date of your last appointment.
State law allows us to release information from Prevea Health, but it does not allow us to release information we have received from other (non-Prevea) clinics, physicians, or hospitals. You will need to sign additional authorization forms (our forms are accepted) then mail them to the other facilities or physician to receive copies of the records kept at their facilities.
As our patient, you have the right to request a personal copy of your medical record. Prevea charges $1.04 per page for the first 25 pages; 77 cents per page for pages 26 to 50; 52 cents per page for pages 51 to 100; and 31 cents per page for pages 101 and above, as well as actual shipping costs and any applicable taxes. If you or your current health care provider request copies of your record to be sent to the provider's office, we will send the copies directly to them at no charge.
Our standard has been to copy and include the past two years of medical care notes and the last year of laboratory results. If you know of any specific information that you wish to have copied and sent - in addition to or instead of this information - please be specific and write it on the release form. Knowing the timeframe (e.g. November 1998 - May 1999) saves on copies.
If you have questions about the record release process, please call (920) 496-4700.
English Medical Release Form
Hmong Medical Release Form
Spanish Medical Release Form