Authorization for Release of Medical Information

For use by a parent, or legal guardian, requesting medical records of a patient

Patient Information
Personal Representative
Supporting Documentation
Authorization to release my medical records
A fee for medical record copies may apply. A patient whose records are copied and sent to another healthcare provider for the purpose of continuing to receive medical care does not pay a fee for medical record copies. Requests for medical record copies for any use other than medical care will be billed as follows:
Fees for medical records will be charged in accordance with applicable State and Federal regulation:
F.S.395.3025 - Fees for medical record copies related to Health facilities and ambulatory surgery
F.S.456.057 - Fees for medical record copies related to Healthcare practitioners and physicians' offices
45 CFR(164.524)(c)(4) - Fees for electronic copy of records.
Information to Release
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Disclosure of sensitive information
You have the right to refuse disclosure and prevent any other person from disclosing sensitive information related to the following conditions, treatments, or testing. To exclude this information from disclosure, check the appropriate checkbox(es). To EXCLUDE this information with disclosure, check the last checkbox in the list.

Delivery Method
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Please Note
Additional information may be needed should demographic information provided not match those in our system.

Please do not submit requests for billing or imaging/films with this form. Contact the respective departments to submit a request for billing records and/or films/images.
Billing Records:
If you are requesting a copy of billing records, you must contact Patient Financial Services at 786-596-6507.
Itemized Billing requests must be sent to:
Baptist Health South Florida
ATTN: Patient Financial Services
PO Box 830880
Miami, FL 33283

Films/Images:
Facility Fax Email or Phone
Baptist Hospital of Miami - BH Imaging 786-533-9579 BHMImageRequest@baptisthealth.net
South Miami Hospital 786-533-9531 SMHImagesRequests@baptisthealth.net
Doctors Hospital 786-533-9712 DHImagesRequests@baptisthealth.net
Homestead Hospital - HHImaging 786-243-8562 HHImagingRequest@baptisthealth.net
West Kendall Baptist Hospital 786-533-9633 DG-WKBHFilmRoom@baptisthealth.net
Mariners Hospital & Fisherman’s Hospital 305-434-1587 DG-MHImagingStaff@baptisthealth.net
Baptist Outpatient Services 786-596-3613 BHMImageRequest@baptisthealth.net
Bethesda Hospital East 561-737-6758 561-737-7733 ext. 84577
Bethesda Hospital West 561-336-7286 561-336-7000 ext. 70250
Boca Raton Regional Hospital 561-955-2139 Imaging@BRRH.COM