Requesting Access to Your Health Information

Your health record includes your medical history, health insurance information and how to contact you.

It is the duty of The Urgency Room to ensure that your record remains confidential and is maintained and released in accordance with applicable laws.

How to request access?

You can request your health record information by completing and sending the appropriate paper form.

Complete and send the appropriate paper form to request and send a copy of your health record to:
- Yourself, using the Patient access for health information form
- Someone other than yourself, using the Request to release and disclose patient information form
The completed form can be sent by:
1. Fax: 952-835-4403 OR
2. Mail: The Urgency Room
            ATTN: Health Information Management/ROI
            4300 MarketPointe Drive, Suite 100
            Bloomington, MN 55435

You can also download the forms here:

Available Monday through Friday from 8AM to 4PM

Send us a secure email:

Name *

Email *

Patient Name *

Requestor Name

Patient Date of Birth *

Date of Service *

Patient Address *

Relationship to Patient (if not the patient)

Message * Include a detailed message with your request. All messages will be responded to via secure messaging. Please check your spam folders.

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