If you been receiving your health care outside of Mayo Clinic Health System, you will need to complete an authorization form to allow that facility to share your medical records with your providers in Chippewa Falls. Transferring your medical records ensures your provider knows about previous health conditions and treatments. The same form also is used to give your permission to share your medical records with another health care provider, system or individual, such as a family member who will assist with your care.

Print the form and complete referring to the instructions on the form, or call the phone number listed on the form for the location you will be visiting for assistance. Sign and return it to Mayo Clinic Health System in one of these ways:

• Fax it to Release of Information. Refer to the fax numbers listed on the form.
• Bring it with you to your next appointment.
• Mail it to the address of the location you will be seen at listed on the form.

Patient/Family History
Family medical history can play a large role in your health. To help you and your provider have a full understanding of your family history, print and complete the Primary Care History form. Bring the completed form to your first appointment.

Privacy and Security
Part of our commitment to caring for you is ensuring your health information is secure. We make it a priority to treat your medical information in confidence while adhering to federal regulations regarding the use and protection of medical and health information.

At your first appointment, you will receive a copy of the Mayo Clinic Notice of Privacy Practices. You will be asked to sign a form required by federal regulations acknowledging that you received it. Signing the form only means you have received the notice and in no way affects the care you will receive here.

If you have any questions about the privacy notice or acknowledgement form, please contact the privacy officer at 715-838-3646.

Call 715-838-6395 if you need assistance or have questions about your medical records.