Forms

How to Obtain Copies of Your Medical Records
In order to obtain copies of your medical records, please download and complete the “Authorization for the Disclosure of Protected Health Information” and send it to the appropriate Bellin site. Authorizations may also be faxed to (920) 433-7910 Bellin Hospital or (920) 433-6779 to Bellin Medical Group.         

Turnaround Time
It takes approximately 3-5 days to complete a request once it has been received. If you need your request sooner, please contact Medical Records.

Copy Fees
There is no charge for copies of your health care records if they are mailed directly to another provider or health care facility. In all other cases, there may be a copying charge to receive copies of medical records. Please contact the Medical Records Department for specific copy fees.

Picking Up Health Care Records
If you plan to pick up copies of your medical records, you must provide us with photo identification for verification purposes. If you are unable to pick up your own records and someone else is picking them up for you, please send a note giving Bellin Health permission to provide your medical records to that person.

Right to Amend Your Protected Health Information
If you feel that your medical records are incorrect or incomplete, you may ask us to amend that information. You have the right to request an amendment for as long as the information is kept by or for Bellin Health. If you are requesting an amendment to your medical record, please download, complete and return this form to:

Bellin Health
Medical Records
744 S Webster Avenue
Green Bay, WI  54305

In certain cases, we may deny your request for an amendment if information: (1) was not created by us, if the person or entity that created the information is no longer available to make the amendment; (2) is not part of the health information kept by or for Bellin Health; (3) is not part of the information which you would be permitted to inspect and copy; or (4) is accurate and complete.

Authorization for Verbal Communication of Health Information
Patients have an opportunity to sign an authorization that will authorize Bellin Health to contact a patient at home and leave detailed messages on their answering machine or with someone else they may have specifically authorized us to share their healthcare information with. In the event we need to reschedule an appointment or change a medication, we would also able to leave detailed information instead of a generic message. If you are requesting to have this form on file, please download, complete and return this form to:

Bellin Health
Medical Records
744 S Webster Avenue
Green Bay, WI  54305

Revocation of an Authorization
You may revoke an authorization, in writing, at any time. You understand that we are unable to take back any disclosures we have already made with your authorization. If you wish to revoke a previously signed authorization, please download, complete and return this form to:

Bellin Health Medical Records
744 S Webster Avenue
Green Bay, WI  54305

Right to Receive an Accounting of Disclosures
You have a right to request an "accounting of disclosures." This is a list of those people with whom Bellin Health may have shared your health information, with the exception of information shared for purposes of treatment, payment or health care operations or when you have provided us with an authorization to do so. We will provide the list at no cost once during each 12-month period. For any additional requests, we may charge you a fee for the cost of providing the list. We will notify you of the fee and you may choose to withdraw or modify your request at that time before any costs are incurred. To request an accounting of disclosures, please download, complete and return this form to:

Bellin Health
Medical Records
744 S Webster Avenue
Green Bay, WI  54305

Questions
For more information, please contact Medical Records at any of our Bellin sites between the hours of 8 a.m. – 5 p.m.