Requesting Release of Your Confidential Records & Information

How to Request Records

An Authorization for Release & Exchange of Confidential Records & Information form is required when:

• You are requesting copies of your confidential records
• You are requesting copies of your confidential records and information be released to another health care provider for treatment.
• You are requesting your confidential records and information be released to other third parties such as your lawyer, the Social Security Administration, your child's school system, etc.

Steps

1. Print and fill out the Authorization For Release form found below.
2. If dropping off the Release in person, a photo ID is required.
3. If mailing the Release, your signature must be witnessed in front of a Notary Public.
4. Mail or drop off the form at:

Request Of Information Instructions for Requesting Records from Winnebago County Department of Human Services

Authorization for Release of Information - English

Authorization for Release of Information - Hmong

Authorization for Release of Information - Spanish

Release of Information Revocation Form

Pick Up

A photo ID will be required if you pick up your own records. If you name someone else to pick up your records, please make him or her aware they will need to show their own photo ID.

Fees

Please note that charges may apply.