Medical Records

Forms
Download the Release of Medical Information form here.
Descargue el formulario de Divulgación de Información Médica aquí.

Please fill out all highlighted sections, including:

1. Patient’s Name, Date of Birth, Address and Phone Number
2. Facility Authorized to Release Information to:
   • Records Released to you – write in “SELF”
   • Records Released to another Provider or Facility – please fill in the Providers name, address, phone and FAX number.
   • Records Released to a personal representative – please fill in the Name, Address, Phone and Fax Number.  Please also note that the personal representative will need to provide copy of <DL> or Official ID in addition to the ID for the patient
   • Health Information to be disclosed – include all dates of service, what type of records you want released (labs, x-ray, complete, etc.), why you need the information (treatment, insurance, personal),
3. Ensure the Sensitive Information section is understood and completed by checking “Yes” or “No”.  Failure to make this selection may delay the release or result in a denial of the request.
4. Patient’s or Authorized Personal Representative’s Signature – please sign, date and time.
   • If the Personal Representative is acting as the POA/HCP and making this request on behalf of the patient, a copy of the documentation naming them POA/HCP should be provided (if not already on file with BBR).
5. Leave the Witness Signature line and everything below it blank.
6. Please include a legible copy of your driver’s license or your Official ID so we may verify your signature with your hospital record. Please note there are fees associated with the ROI process that are governed by State and Federal Guidelines. If a patient request is less than 10 pages, there will be no fee. If the patient request is 10 pages or more then an appropriate fee will be assessed, and an invoice will be submitted for payment.