Forms

How to Obtain Copies of Your Medical Records

  1. Medical records can be requested through your MyBellinHealth account.
  2. Medical records can be obtained by completing the  “Authorization for the Disclosure of Protected Health Information” and mailing it to P.O. Box 23400, Green Bay, WI 54305-3400.   Authorizations may also be faxed to (920) 433-7909 for Bellin Hospital and Bellin Medical Group or Bellin Psychiatric Center/Bellin Behavioral Health (920) 437-0533.

Turnaround Time
It takes approximately 7-10 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 sent 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 Medical Records for specific fees.

Picking Up Health Care Records
If you plan to pick up copies of your medical records, you must provide a photo identification for verification purposes. If you are unable to pick up your own records and someone else is picking them up for you, an authorization must be completed allowing that individual to do so.

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
Health Information Management
744 S Webster Avenue
Green Bay, WI  54305

In certain cases, we may deny your request for an amendment of 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.

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 notify medical records:

Bellin Health
Health Information Management 
744 S Webster Avenue
Green Bay, WI  54305
(920)433-3557

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
Health Information Management
744 S Webster Avenue
Green Bay, WI  54305

Questions
For more information, please contact Health Information Management at any of our Bellin sites between the hours of 8 a.m. – 4 p.m.