Requests for Medical Records
Please be advised that it is our policy at Brookhaven Retreat to only release confidential medical information when a client has completed our approved release of information form. We have attached a copy of our Authorization for Release of Confidential Information form to be completed by the client. Please note that this will have to be completed in its entirety and will require notarization. We require the original notarized release mailed back to us. We are unable to accept a faxed or scanned copy of this form. Once we have received this, we will be more than willing to release any requested information. See the instructions below for a description of how to properly fill out the release.
- Please fill out your name and date of birth at the top of the form.
- If this release is to request your record be sent to yourself, please fill out your name and the address where you want the record sent. If you are releasing to another person, specify the name of the person or agency that you are requesting we release records to, along with their mailing address and phone number.
- Make sure to put a mailing address. This package will have to be signed for upon delivery. (Include a fax number if you want records to be faxed to them. Please note we will only fax a limited amount of information, on a more emergency need basis.) If you are requesting the entire record, it will be mailed and is typically only released to you.
- Please indicate a reason for the request and then check the appropriate box(es) for information to be released. If you do not see a box for what you desire, then check “other” and write a description of the information. For your protection, please draw one line through any item next to an unchecked box, to indicate that this is not a part of the record you want selected.
- You will need to put an expiration date on the release to state when this authorization will expire. We will not release any requested information beyond that date.
- Please sign and date the bottom portion as you have it notarized.
Mail the original notarized release back to us and we can begin to process the records request at that time.
Please, only include one person or agency per release. You will need to fill out multiple copies for more than one destination.