Request for Access to PHI

Patient Information

First Name

MI

Last Name

Date of Birth

Email

Phone

Personal Representative

First Name

MI

Last Name

Email

Phone

Confirm Email

Confirm Phone

Mailing Address

Please check at least one box.
Supporting Documentation

Your relationship to the Patient

Parent/Foster Parent

Guardian

Medical Power of Attorney

Executor of Estate

Document Upload

The facility has documented proof of my relationship to the patient on file. i

I have documentation to support my relationship to the patient and will provide it to the Baptist Health representative today i

Upload supporting document(s) (Court Order or Medical Power of Attorney):

Authorization to release my medical records

I authorize

to disclose to

Self

or to

Named person or entity

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.

Recipient Name

Recipient E-mail:

Recipient Phone

Recipient Fax

Mailing Address

Information to Release

What to Release (check all that apply)

Resumen de expedientes médicos i

Cirugía ambulatoria i

Informes de cardiología i

Informes de consultas i

COVID-19 Report i

Resumen de alta i

Expediente del Departamento de Emergencias (ED) i

Ingreso en el hospital i

Antecedentes y examen físico i

Resultados de pruebas de laboratorio i

Informes quirúrgicos i

Expediente de paciente ambulatorio/consultorio del médico únicamente i

Informes de patología i

Notas del consultorio del médico i

Informes de radiología i

From Date i

To Date i

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 listed below. Please note only the items you check below will be released and no information will be released without your explicit consent. Include (indicate by checking below):

Psychological/Psychiatric conditions i

Drug and/or alcohol abuse diagnosis and/or treatment i

HIV AIDS diagnosis and/or treatment i

Genetic Testing i

I authorize the disclosure of ALL sensitive information

I DO NOT authorize the disclosure of ANY sensitive information

* If you select the option to not release any sensitive information, your records will have all sensitive information redacted. Please note that the information will not be released if you do not check at least one box.

Delivery Method

Released By

Email i

Mail Paper Records i

Dates of service

Consent Expiration Date i

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	786-260-0517	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

Review and submit

Cancel my request for records

Authorization for Release of Medical Information

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

Patient Information

Personal Representative

Please check at least one box.
Supporting Documentation

Authorization to release my medical records

Information to Release

Disclosure of sensitive information

Delivery Method

Please Note

Authorization for Release of Medical Information Autorización para Divulgar Expedientes Médicos

For use by a parent, or legal guardian, requesting medical records of a patient Para su uso por parte de un padre o tutor legal que solicite el expediente médico de un paciente

Patient Information Información del paciente

Personal Representative Representante personal

Please check at least one box. Por favor marque al menos una casilla. Supporting Documentation Documentación de apoyo

Authorization to release my medical records AUTORIZACIÓN PARA DIVULGAR MIS EXPEDIENTES MÉDICOS

Information to Release INFORMACIÓN QUE SE DIVULGARÁ

Disclosure of sensitive information Revelación de información sensible

Delivery Method Método de entrega

Please Note Tenga en cuenta

Authorization for Release of Medical Information

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

Patient Information

Personal Representative

Please check at least one box.
Supporting Documentation

Authorization to release my medical records

Information to Release

Disclosure of sensitive information

Delivery Method

Please Note