Please fill out all highlighted sections, including:
- Patient’s Name, Date of Birth, Address and Phone Number
- 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),
- 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.
- 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).
- Leave the Witness Signature line and everything below it blank.
You will also need to include a legible copy of your driver’s license or your Official ID so we may verify your signature with your hospital record.