Medical Records Information

As a patient, you have the right to get a copy of your medical record.  Please follow these simple steps to request a copy of your medical record free of charge.  

Step 1:  Complete an authorization in writing for Rogers to release your information.

Please print and complete the form.

English form

Spanish form

Instructions for Completing Authorization to Release Protected Health Information

Spanish Instructions for Completing Authorization to Release Protected Health Information

*Please note, due to state and federal laws, we are unable to process incomplete forms.

Step 2:  Submit your request to the Release of Information Team at Rogers.

  • By mail:  

    Rogers Behavioral Health
    Health Information
    34700 Valley Road
    Oconomowoc WI 53066

  • By fax:  262-646-5745

  • By Email:  releaseofinformation@rogersbh.org

Your request will be completed within five to seven business days from the date it is received.

For questions, please call or email the Release of Information Team:
Phone:  800-767-4411, Option 3
Email:  releaseofinformation@rogersbh.org

HIPAA Notice of Privacy Practices

Revocation of Authorization to Release Information

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Call 800-767-4411 or go to rogersbh.org to request a free screening.