Forms

Ways to Obtain Your Medical Records

  1. Contact our Health Information Management Department by calling and requesting your medical records at (920) 433-3557.
  2. Medical records can be requested through your MyBellinHealth account.

    Steps:
    1. From menu, locate the Communication section
    2. Select Ask a Question
    3. Click Ask a customer service question
    4. Click Record Request

  3. Medical records can be obtained by completing the Authorization for the Disclosure of Protected Health Information form and mailing it to P.O. Box 23400, Green Bay, WI 54305-3400. Authorizations may also be faxed to (920) 433-7910 for Bellin Hospital and Bellin Medical Group or Bellin Psychiatric Center/Bellin Behavioral Health (920) 437-0533.

    Please note: Bellin Health clinic staff are unable to release medical records.

Turnaround Time
Once received, it takes approximately 3-5 business days to complete a request. If you need your request sooner, please contact Health Information Management.

Copy Fees
There is no charge for copies of your medical record if it is sent directly to another physician or healthcare facility. Documents requested for any other reason may be subject to a processing fee. Please get in touch with Health Information Management for more information.

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 cannot pick up your own records and someone else is picking them up for you, authorization must be completed allowing that individual to do so.
Patient privacy and confidentiality are essential to Bellin Health. Our Health Information Management department staff are trained professionals who follow HIPAA privacy rules to ensure the confidentiality of every patient’s health information.

Right to Amend Your Protected Health Information
If you feel 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 Request for Amendment/Correction form to:

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

In some instances, 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 cannot remove any disclosures we have already made with your permission. 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 with whom Bellin Health may have shared your health information, except for information transmitted for treatment, payment, healthcare operations, or when you have authorized us to do so. We will provide the list at no cost once during each 12 months. We may charge you a fee for any additional requests for 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 Request for an Accounting of Disclosures form to:


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

Questions
For more information, please contact Health Information Management between 8 a.m. – 4 p.m.