An authorization form is required when requesting copies of medical records for personal reasons or if you are requesting your records be made available to another party. If you need copies of records sent to another health care provider, you may do one of the following:
1. Download, print and submit the form below to:
Holy Family Memorial
Attention: Release of Information
P.O. Box 1450
Manitowoc, WI 54220
2. Call the Release of Information Department at 920.320.2278
In some cases, a fee will be charged for medical record copies. Our Release of Information department will be happy to provide you with information regarding any fees, turnaround time, or answer any questions you have regarding your medical records.
The authorization form is not valid if one or more required fields are left blank. Complete all required fields in order for your request to be processed.
Download and print Authorization for Disclosure of Information Form