How to complete Medical Release

There are two (2) convenient ways to use the form:

  1. Print the form and complete.
  2. Type the information on the form and then print to your printer

1. Provide Patient Name and Date of Birth

2. “I authorize” field – Enter which medical facility you are requesting the records from.

  • Example: I authorize Lake Health Clinic or Lake District Health

3. Purpose:  Check the box that applies to the reason you are requesting your records.

4. To: Enter the name where the records should be sent, please complete all information n this section.

5. Initial the records to be sent.

  • Example: Emergency room visit(s)
ROI instructions

6. IMPORTANT:  If you wish to send records for HIV/STI, Drug/Alcohol, Genetic Testing and Mental Health, you will need to initial each field.

7. Date and Sign the form. 

8. Electronic Transmission (Email)

  • If you wish to have your records emailed to YOU, you must complete the remainder of the form
  • Make sure to initial the unsecured section
  • Provide your email address

Request an Appointment

* All indicated fields must be completed
Please include non-medical questions and correspondence only.

Visit Our Lakeview Location

Open 24 Hours

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