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 your records, you may do one of the following:
1. Download, print and submit the form on this page to:
- Holy Family Memorial
- Attention: Release of Information
- P.O. Box 1450
- Manitowoc, WI 54221-1450
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.