Patient Request

Patient Personal Request

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Patient Information

First Name*

Last Name*

Date of Birth*

Requester Information (Patient, Parent/Guardian or Conservator)

Relationship to Patient

Name (if different than the Patient)

Preferred Notification Method

Mobile Phone (By selecting “Mobile Phone” for your notifications, you are agreeing to receive text messages from BHS Connect. You may opt out at any time by responding “Opt out” to the text message)

Email (Please check entire inbox for an email from secure-transfer@bhsonline.info)

Email Address where a secure link to your records will be sent*

Confirm Email Address *

Mobile Phone Number *

Confirm Mobile Phone Number *

Other Phone Number(optional)

Type of Number

Patient/Requester Driver’s License* (PDF, JPEG, PNG, GIF, TIFF)

Guardian/Parent/Conservator Healthcare Authority Documents (PDF, JPEG, PNG, GIF, TIFF)

What would you like released? Check all that apply.*

Office/Clinic Notes

Operative Reports

Lab/Pathology Results

Radiology Reports

Immunization Records

Only Last Two Years of Records

Dates To

Other

This authorization shall stay in force and effect until two years from date of submission at which time this authorization expires. If you wish the authorization to expire before two years, please click "Other" above and let us know when the authorization should expire.

If you do not want certain portions of your medical records released, please check the categories listed below you would like excluded.

Substance Abuse, if any

AIDS/HIV/STDs, if any

Psychological/Psychiatric conditions, if any