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Records and Forms

Records and Forms

If you need to request your medical records, click on the link below. A PDF will pop up on your screen. Print this form, fill it out, and bring it in or mail it to Wilmington Health, Medical Records Department, 1920 South 16th Street, Wilmington, NC 28401.

Medical Records Request Form

Authorization to Release Medical Records
Pediatric Patients' Authorization to Release Medical Records

Instructions for Completing the Authorization Form

Provide your full name, date of birth, and a phone number where you can be reached during business hours.

Complete the numbered blanks as follows:

  1. Enter the name of the organization/facility/person with the information to be disclosed. If this is not Wilmington Health, provide the full address.
  2. Enter the name of the organization/facility/person you want the records sent to. Again, provide the full address if this is not Wilmington Health.
  3. Indicate specifically which records you want to have copied. Examples: all pediatric records, ortho records regarding shoulder injury, obstetrical records from 2000 to present.
  4. State the purpose for your disclosure. Examples: claim determination, workers comp. case, attorney, personal request.
  5. Review form to ensure all areas are complete.
  6. Sign and date it. If you are not the patient, please indicate your relationship to the patient and present supplemental documentation. Examples: Healthcare Power of Attorney if the patient is 18 years or older, Custodial papers if you are the legal guardian, or Death Certificate and Letter of Administration if the patient is deceased.

If you have questions, please call 910.341.3308 for assistance.