Third Party Request

required field

Patient Signed Authorization Form *

To request a patient’s medical records, you must upload a Patient-Signed Authorization Form. This form must be completed and signed by the patient or their legal representative to comply with privacy regulations.

Upload File
(pdf, jpeg, png, gif, tiff)

Step 2: Third Party Requester Information

Please include the name, address, phone number, fax number, and email address of where you want the record sent

To receive status updates for this request at the email address above, please select the option below.

Email (Please check your regular inbox and any junk / spam inboxes for emails from secure-transfer@bhsonline.info to ensure timely access.)

Step 3: Types of Records

Documentation of Materials Requested *

Office/Clinic Notes

Operative Reports

Last One Year of Records

Dates To

Other

Step 4: Medical Imaging Records Request

Options

Copy of X-Rays images

Copy of MRI images

Copy of CT images

Step 5: Purpose of Release

This protected health information is being used or disclosed for the following purposes: *

Attorney or Legal

Insurance

Government Agency

Other

Please provide detailed explanation of the purpose of this medical record request.*

Step 6: Receiving Records *

Fax to the Third Party Requester fax number above

Email a secure link to the Third Party Requester

Mail to the Third Party Requester address above (Mailing records will incur a postage fee and may extend delivery time)

*Medical (X-ray, CT, MRI) images requested in Step 4 will be sent electronically via a secure portal link

Step 7: Submit

Prohibition of re-disclosure: *

This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, and HIV/AIDS tests results, federal requirements (42 CFR Part2) and state requirements (IA Code ch.228&ch.141)(740 III. Comp Stat. § 110/5)(Wis. Code §§252.15(6), 50.30) prohibit further disclosure without the specific written consent of the patient, or as otherwise permitted by such law and/or regulations. A general authorization for release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may result from unauthorized disclosure of alcohol/drug abuse, mental health or HIV/AIDS related testing and or treatment.

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