Often, it is useful and necessary to obtain information from other healthcare providers who have evaluated or treated you in the past.  Additionally, sharing clinical information with other providers currently involved in your treatment can be essential to the coordination of care.

We use the form below to obtain your permission to exchange or receive information from other healthcare providers, from medical facilities, and from other institutions that maintain confidential records of your protected health information.  Your provider may ask you to execute this form, after they have completed the fields that pertain to the type of information to be requested.  Obviously, your provider will address whatever questions you may have about the privacy of your protected health information.

To fill out this form online, click the Download link on the left.  When you are finished with the portion that you can complete online, print it, and complete the circled items by hand.

Download (PDF, 266KB)


Do not use this form in an attempt to schedule an appointment.  Again, please  submit this form only after you have already scheduled an appointment with one of our Providers.  Forms submitted without a scheduled appointment will not be reviewed, and you will not be otherwise contacted.

All health and health-related information contained within this WPAPC website is intended to be general in nature and should not be used as a substitute for a visit with a health care professional. No information provided in this site may be considered medical advice. The information may not be relevant for your individual situation and may be misinterpreted. WPAPC assumes no responsibility for how you use information obtained from this site. Before making any decisions regarding your health care, ask your personal physician.

Please be aware that most information transmitted over the Internet is not secure; thus, confidentiality cannot be guaranteed. Information of a confidential, proprietary or privileged nature should not be sent electronically to WPAPC. Any patient information transmitted to our site will be treated as non-confidential. Personal medical information should never be sent to our website.