For Patients Requesting Their Records:
Click on the button below to print the Release of Information form. It is very important that you complete each section of the entire form, sign and date. Please fax or mail your completed and signed ROI form, along with a copy of your photo ID to the address or fax number below, or you may bring it in to any of our office locations.
IF YOUR REQUEST INCLUDES 10 PAGES OR MORE OF YOUR PROTECTED HEALTH INFORMATION, YOU WILL BE CHARGED $6.50.
If your request includes mammogram films or if your records must be delivered within 48 hours, please contact our office directly at 260-432-4400. Our mailing address is as follows:
Women's Health Advantage/Medical Records
2518 E. Dupont Rd.
Fort Wayne, IN 46825
FAX (260) 969-6898
For All Other Parties Requesting Records:
Print, complete and fax the online form or you may also use your own records request form and fax to the above listed number. If you have a single request or your patient is already in office, please feel free to contact us directly.
*Please allow 5 to 10 business days to process your request.