You may request the release of your confidential patient information to go to yourself or to any other healthcare provider or representative you choose.

For your convenience, click here to print a copy of the hospital Authorization for Release of Protected Health Information (PHI). To avoid delays in processing your request, please complete all areas, and sign and date the authorization.

If the request is for an electronic copy (on a CD) of the PHI maintained in Brookhaven Memorial Hospital Medical Center’s electronic health record, BMHMC staff will respond to the request within three (3) days of receipt of the Request Form.

Please mail or hand deliver the completed authorization to:

Brookhaven Memorial Hospital Medical Center
Health Information Management Department
101 Hospital Road
Patchogue, NY 11772

We are open weekdays from 8:00 a.m. – 4:00 p.m. Please remember to bring your picture ID with you. We are conveniently located on the first floor of the hospital. Please stop at the reception desk in the front lobby for directions.

Once your request is received, the hospital may take up to 10 days to process it. There is no charge to send your medical records to another healthcare facility and/or provider. If you are requesting this information for your own use, the hospital charges a fee of $.75 per page. You would then receive a bill for the copy that you requested. Should you decide to pay for the copy and would like to pick it up, please call the HIM Department at 631-447-3062 or 631-654-7710 prior to coming to HIM so that the copies are available for you to pick up.

If you have any questions regarding the release of your confidential patient information, please feel free to call the Health Information Management Department, weekdays from 8:00 a.m. to 4:00 p.m. at 631-654-7710.

REQUEST A COPY

To request a copy of your Brookhaven Memorial Hospital medical records, send a completed and signed Authorization for Release of Protected Health Information (PHI) to:

Health Information Management Department
Brookhaven Memorial Hospital Medical Center
101 Hospital Road
Patchogue, NY 11772

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