Request Your Chart

You may request a copy of your medical records at any time.  While we try to make this as convenient as possible, a signature is required before any information can be released.  The following options are available at this time:

  • If you would like your records sent out, complete the request, print the request, sign it and mail it or drop it off at the clinic. Your records will be copied and sent per your request.

  • Mailing Address:
    St. Cloud Medical Group
    Attn: Universata
    251 County Rd 120
    St. Cloud, MN 56303

  • Fax: 320-251-6942
  • Charges will apply (Maximum of $11.00).  Your billing will come directly from Universata, the company we contract with for this service.
Authorizes

St Cloud Medical Group, P.A., 251 County Rd 120, St Cloud, MN 56303
St Cloud Medical Group, P.A., 1301 33rd St S, St Cloud, MN 56301
Clearwater Medical Clinic, 615 Nelson Dr, Clearwater, MN 55320
Cold Spring Medical Clinic, 402 N Red River Ave, #2, Cold Spring, MN 56320
Midwest Occupational Medicine, 1301 33rd St S, St Cloud, MN 56301

An Asterisk (*) indicates a required field.

Patient Info






Health Care Provider






Release Information    
Entire Record
Medical History, Examination, Reports
Treatment or Tests
X-Ray Reports
Laboratory Reports
Consultatoins
Surgical Reports
Hospital Records including Reports
Allergy Records
Prescriptions
Other (Specify):


I understand that only protected health information generated by SCMG can be released or disclosed.)

Mental Health
Alcoholism
Drug Abuse
Sexually Transmitted Diseases
HIV (Aids)
Developmental Disabilities
Other (Specify)