A completed Authorization Form signed by you or your legal guardian is required to release your information. You may fax your completed form to us at 920-887-6691, email to us at medicalrecords@marshfieldclinic.org OR mail to us at:
Marshfield Medical Center-Beaver Dam
Health Information Management
707 S. University Ave.
Beaver Dam, WI 53916
Our Confidentiality Policy
MMC-BD follows applicable Federal and State Laws regarding the confidentiality of patient information. The Federal Law is known as HIPAA (Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164). The Wisconsin Law is “Wisconsin Statutes, Chapter 146, Miscellaneous Health Provisions.”
MMC-BD releases patient information only when a valid authorization signed by the patient or the patient’s legal guardian is received by MMC-BD. There is an exception to this: The patient’s written authorization is not needed for MMC-BD to release patient information directly to another health care provider.
The patient must sign an authorization directing MMC-BD to release copies of the patient’s medical record to anyone who is not a health care provider. Please note that copy fees apply on all releases to anyone other than directly to a health care provider. The patient’s POA (Power of Attorney) cannot sign the authorization unless (1) the POA form states the POA has the right to sign the authorization to release information, and (2) a “Statement of Incapacity” has been received by MMC-BD and has been filed into the patient’s medical record.
There are certain instances related to the treatment of alcohol and substance abuse, mental health and reproductive issues where the minor and not the parent/legal guardian must sign the authorization to release information.
Copy Fees, per State Law, apply to release of information (no fee is charged for copies sent directly to another health care provider):
Annual Adjustment to Fees That May be Charged by a Health Care Provider for Providing Copies of a Patient’s Health Care Records
Pursuant to Wis. Stat. §146.83 (3f) (c) 2., each July 1, beginning on July 1, 2012, the Department of Health Services is required to adjust, by the percentage difference between the consumer price index for the 12−month period ending on December 31 of the preceding year and the consumer price index for the 12−month period ending on December 31 of the year before the preceding year, the dollar amounts specified under Wis. Stat. §146.83 (3f) (b) that a health care provider may charge for providing copies of a patient’s health care records.
Under the methods prescribed in Wis. Stat. §146.83 (3f) (c) 2., the adjusted dollar amounts that a health care provider may charge for providing copies of a patient’s health care records are listed here.
Marshfield Medical Center-Beaver Dam does not maintain copies of Birth Certificates.
Please contact the Dodge County Register of Deeds, 3rd Floor, Dodge County Administration Building, 127 East Oak Street, Juneau, Wisconsin 53039, call 920-386-3720, or visit www.co.dodge.wi.gov/government/departments-p-z/register-of-deeds
Copies may also be obtained from the State of Wisconsin, Department of Health and Family Services, Office of Vital Records. For more information about this, go to https://www.dhs.wisconsin.gov/vitalrecords or call 608-266-1373.
In order to protect your confidentiality, patient information is faxed only to other health care providers.
You may use the Wisconsin Immunization Registry (WIR) to check on your own or your family’s immunization status.
http://www.dhs.wisconsin.gov/immunization/wir.htm