Protected Health Information
Bellin Health respects your right to the protection and privacy of your personal health information. We make every attempt to protect your information so that it's not heard, read or otherwise shared for any reason. A signed authorization form from the patient or a legal guardian is required to disclose this information.
The healthcare record is the property of Bellin Health and is maintained for the use of the hospital, clinic and medical staff at the patient's benefit. Please note that clinic staff are unable to release medical records.
You may request a copy of your medical records at any time. An easy way to access your protected health information (PHI) is through your MyBellinHealth patient portal.
Log in—anytime, anywhere—to securely view your records, manage who sees your PHI or connect your account to other health systems. You may also request a copy of your medical records using the process below.
Ways to Get Your Records
Patient Portal
- Medical records can be requested through your MyBellinHealth account by following these simple steps.
- Click on Messages button on top toolbar
- Click on Send a message button
- Click on Ask a customer service question
- Click on Record Request
Mail or Fax
- Complete the Health Information Disclosure Authorization form and return to us.
- Mail: Bellin Health
Attn: Release of Information
P.O. Box 23400
Green Bay, WI 54305 - Fax: (920) 433-7909
Contact Us
- Call our Release of Information Department at (920) 433-3557 to request your medical records or check the status of a medical records request.
Release of Information Department
Normal Business Hours
- Monday - Friday: 8 a.m. - 4 p.m.
- Closed weekends and holidays
P.O. Box 23400
Green Bay, WI 54305
United States
Follow the steps to have your records transferred to Bellin Health:
- Contact the clinic location where you'll be seen to guide you through the process, provide you with our forwarding address and answer any questions you may have.
- Reach out to your previous healthcare facility and request a transfer of records.
- Complete your medical records release form and return it to your previous facility prior to your scheduled appointment.
Accounting of Disclosures
You have a right to request an accounting of disclosures. This is a list of those with whom Bellin Health 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 a list at no cost once every 12 months. We may charge you a fee for any additional requests.
To make a request, complete and return our Accounting Disclosures form by mail to:
Bellin Health - Release of Information
P.O. Box 23400
Green Bay, WI 54305
Amend Your Records
If you feel like your medical records are incorrect or incomplete, you have the right to request an amendment as long as the information is kept by or for Bellin Health. If you are requesting an amendment, please complete and return a Request for Correction form by mail to:
Bellin Health - Release of Information
P.O. Box 23400
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.
Birth Certificate Information
To get a copy of a birth certificate, you must request a copy from the County Register of Deeds in which you were born. Bellin Health does not have copies of birth certificates. To access information as to how to get a copy of a birth certificate, please refer to the following:
Request on Behalf of Someone Else
If you request records for someone other than yourself, you must provide legal documentation verifying guardianship, power of attorney, personal representative, etc. Parents may request copies of their minor child’s records as long as they have parental rights. A completed authorization form is required to obtain medical records on someone other than yourself.
Note: For billing information, please contact Patient Financial Services at (920) 445-7210.
Revoke an Authorization
You may revoke authorization in writing at any time. Understand that we are unable to take back any disclosures already made with your authorization. Please notify medical records if you wish to revoke a previously signed authorization.
Bellin Health - Release of Information
P.O. Box 23400
Green Bay, WI 54305
Records Turnaround Time
It takes 3-5 business days to complete a patient and continuity of care request once received. All other requests may take longer than 3-5 business days.
We realize there are circumstances when your medical record will require immediate disclosure. If you need your request sooner, please get in touch with our Release of Information Department at (920) 433-3557.
Student Athlete Health Forms
If you're requesting to have Bellin Health Sports Medicine provide athletic training coverage for a student athlete or team event, please download and complete our treatment consent and health authorization forms.
- Treatment Consent Form (English)
- Health Information Authorization Form (English)
- Treatment Consent Form (Spanish)
- Health Information Authorization Form (Spanish)
- Treatment Consent Form (Hmong)
- Health Information Authorization Form (Hmong)
- Treatment Consent Form (Somali)
- Health Information Authorization Form (Somali)
View or Obtain Your Records
You have the right to view or request copies of your healthcare records. Please make an appointment with the Release of Information Department to view or obtain your records. Our department staff are trained professionals who follow HIPAA privacy rules to ensure the confidentiality of every patient’s health information.
Our electronic request form gives outside clinicians and professionals access to Bellin Health's electronic medical record system. Your submission will be sent to our Interoperability Team for review and responded to within 30 days.