If you would like to have copies of your previous medical records sent to GHC-SCW, please take the following steps:

• Download and print the Authorization to Release Medical Information to GHC-SCW
• Complete the patient’s name, SS#, daytime phone #, and date of birth.
• Complete the name and address of the person/facility that the records are to be obtained from.
• Identify the appropriate dates of service for the records that are to be released.
• Check the appropriate information that is to be released (copied and/or faxed).
• Review your rights for this authorization.
• Review the expiration date of the authorization. If you would like a different expiration date, please indicate.
• Obtain the patient or legal representative’s signature (relationship) and date.
• If this request relates to AIDS/HIV, Mental Health Care, Alcohol/Drug Use, or Development Disabilities, please sign and date under the specified section.
• Mail the completed request to your previous health care facility. You may need to contact your previous clinic for information on where to mail or fax the completed form. If this is sent to GHC-SCW, this will only delay the process of your GHC-SCW provider receiving copies of your prior health records.
• Your previous clinic will process your request, and send the information to GHC-SCW.