Electronic Request Form

Cures Act

Our electronic medical record request form is for outside clinicians & professionals to make requests to access the Bellin Health Electronic Medical Record System. Your submission will be sent to our Interoperability Team for review and responded to within 30 days.

If you are requesting individual medical records release, please utilize MyBellinHealth or call Bellin's Health Information Management at (920) 433-3557.

Fully complete the questions below.