Patients and Visitors

Medical Records

The form below is an Authorization for Use or Disclosure of Health Information form. Complete all areas of the form that pertain to the records you are requesting. Please be sure to include the specifics of what records you are requesting and where you would like those records sent.

Authorization for Use or Disclosure of Health Information

Healthcare Permission for Verbal Communications and/or to Leave Messages

Contact Us

If you have questions or need additional information, please do not hesitate to contact:

Tracy Graney, Disclosure Specialist, Health Information Management
608.723.3265
608.723.3354 (fax)
tgraney@grantregional.com