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John Albert, MD

Katherine Finn, DO

Suhail Hameed, MD

Jonathan Kushi, MD

Arnold Lim, MD

Farrukh Pasha, MD

Kurt Oelke, MD
Diseases

Lupus

Sjogren's Disease

Osteoporosis

Sarcoidosis

Behcet’s Disease

Uveitis

Polymyalgia Rheumatica

Vasculitis

Psoriatic Arthritis

Gout

Ankylosing Spondylitis

Osteoarthritis

Rheumatoid Arthritis

Scleroderma

Myositis
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New Patient Form

RDC Patient Medical Records Request

Pay Your Bill *Payment Note

Important Notice

Beginning April 1, 2026, our clinic will implement a surcharge for credit card transactions. This change helps cover increasing processing fees and allows us to continue providing quality care and services.

          To avoid this surcharge, you are welcome to use:
          Debit card
HSA/FSA card
Check or Money Order

        

Thank you for your understanding and cooperation.

Rheumatic Disease Center

Medical Records Request Form

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* Required fields

1

Patient Information

Full Name *

Date of Birth *

Phone Number *

Email Address

Mailing Address

2

Record Request Details

Please check all that apply:

Complete medical record Office visit notes Laboratory results Imaging reports (X-ray, MRI, CT, ultrasound) Pathology reports Infusion records Medication history Billing records Other

If "Other", please specify

3

Date Range of Records Requested

From Date *

To Date *

4

Purpose of Release

Please indicate the reason for requesting records (check one or specify):

Continuation of care with another provider Personal records Insurance / disability claim Legal purposes Second opinion Other

If "Other", please specify

Additional Details (optional)

5

Treating Providers (if known)

Dr. Katherine Finn Dr. John Albert Dr. Jonathan Kushi Dr. Arnold Lim Dr. Farrukh Pasha Dr. Suhail Hameed Dr. Kurt Oelke Other

If "Other", please specify

6

Delivery Method

Select one delivery method:

Mail paper copies Pick up in person Secure electronic delivery (portal / email)

If electronic delivery, provide email

7

Authorization & Signature

I authorize the Rheumatic Disease Center to release my medical records as requested above.

Patient Name *

Date *

Patient Signature *

Draw your signature above using mouse or touch

If Not Signed by Patient — Complete Below

Representative Name

Relationship to Patient

Authority

Parent Guardian Power of Attorney Other

Representative Signature

Date

8

Office Use Only

Staff Only

Date Received

Processed By

Date Completed

Notes

✓ Form submitted successfully!

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Required Information Missing

Please complete the following before submitting:

Rheumatic Disease Center

Phone (appointments): 414-351-4009

Fax: 414-351-7060

Diseases

Lupus
Sjogren's Disease
Osteoporosis
Sarcoidosis
Behcet’s Disease
Uveitis
Vasculitis
Psoriatic Arthritis
Polymyalgia Rheumatica

Gout
Ankylosing Spondylitis
Osteoarthritis
Rheumatoid Arthritis
Scleroderma
Myositis

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