Patient Information Request

At Broward Outpatient Medical Center, we are familiar with the insurance and legal aspects of claims.  To make the process as efficient as possible and still maintain compliance with HIPAA, we have fully digitized the patient information format and request.  

HIPAA Medical Records Release:  If you are requesting patient information for the first time, it it is important that you file a HIPAA Release Form, or we will not be able to release the patient's files to you on request. For a copy of an executable HIPAA Medical Records Release form, please click here: HIPAA Medical Records Release form. Please email the signed HIPAA release to Patientadvocateteam@Browardoutpatient.com

Patient Medical Records Request: Please fill out the form below and your request will be addressed within one (1) business day. If there are issues or concerns with the request, you will be contacted by the information provided.


 
The Person Making the Request
What is YOUR name? *
What is YOUR name?
What is YOUR phone number?
What is YOUR phone number?
Who are you: *
If you are "another party," who are you?
The Patient Information
What is the PATIENT's name?
What is the PATIENT's name?
What is the PATIENT's date of birth?
What is the PATIENT's date of birth?
What information are you requesting about the Patient? *
Confirmation
By typing your name, you are confirming your request for the records is for the legitimate purpose stated above, that you are the person identified above, under penalty of perjury.