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Waukesha Memorial Hospital (ProHealth Care) fax number
(262) 544-9489
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Health Information Management / Medical Records
Used for: Submitting MyChart Inactivation Form to deactivate proxy access and manage patient data releases (MyChart inactivation).
Fax destination details
- Department
- Health Information Management / Medical Records
- Purpose
- Submitting MyChart Inactivation Form to deactivate proxy access and manage patient data releases (MyChart inactivation).
- Form
- AD-40 — MyChart Inactivation Form
- Address
- 725 American Ave, Waukesha, WI 53188
- Voice phone
- 262-928-1000
- Website
- Visit organization website
Before you send
- Confirm that this exact department handles your document or request.
- Check the organization website or call its main line for the current fax number.
- Include a cover sheet and any case, member, claim, or form reference required.
- Keep the delivery confirmation with your submission records.
Fill out the Inactivation Form as shown in the document and submit by fax to 262-544-9489 or mail to Health Information Management, ProHealth Care, Inc., N17 W24100 Riverwood Drive, Waukesha, WI 53188.
Official form instructions are published as a downloadable file on the organization's website.
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