Release of Information
How do I get a copy of my medical records?
If your hometown physician or a medical specialist requests a copy of your Sindecuse Health Center medical record, you must sign an authorization before we can send it. Information from your medical record is never shared with any area of the University, or with any administrator, faculty or staff member without your written consent, except as required.
Medical records requests are processed as promptly as possible but requests should be made as early as possible. Authorization forms may also be obtained from the health care provider requesting your records. This form asks you to identify the physician or medical office requesting the records.
Print theRelease of Information (Authorization) form and fill the front side out completely according to the instructions below.
- Fill in all identification information on the top four lines.
- If Sindecuse will be sending information to another person/provider, circle "from" Sindecuse and "to" the person/provider. Please fill in the complete address, telephone, and fax numbers.
- If Sindecuse will be receiving information from another person/provider, circle "to" Sindecuse and "from" the other provider. Please fill in the complete address, telephone, and fax numbers.
- Check the box beside the parts of the medical record you want sent or requested. If you are not sure of what parts should be checked, please leave a message for us at (269) 387-3283.
- Check in the box regarding the purpose for this request.
This authorization is good for one year. You may change this time by filling in another date or event (e.g. graduation from WMU). If you are 18 or older, be sure to sign and date the form.
If you are under 18, a parent or guardian must sign and date the form and list the relationship to the patient. This release of information becomes invalid on the patient's 18th birthday.
- Fax this form to (269) 387-4494, Attn: Medical Records
- Or, mail it to:
Sindecuse Health Center
Western Michigan University
1903 W Michigan Ave
Kalamazoo MI 49008-5445
- Or, bring the signed authorization and a picture ID to Sindecuse Health Center.
If you are unable to view these forms, download and install Adobe Reader.
- Asthma Progress Note
- HIPAA Acknowledgement - for receipt of notice of privacy practices*
- Notice of Privacy Practices *The Health Insurance Portability and Accountability Act Privacy Rules (federal regulations that became effective April 14, 2003) provide important protection for health information including that your authorization is obtained in certain circumstances. The Privacy Rules apply to the use and disclosure of Protected Health Information by entities providing medical care and treatment.
- Patient Insurance Information
- Medical Treatment Authorization
- Medical History and Screening
- Medical Treatment for On-the-Job Injury WC 210
- Payroll Deduct (Express Pay) Enrollment
- Travel Consultation
- WMU Accident/Injury 311 Report
WMU Sports Medicine Clinic forms
For more information
Call (269) 387-3287.