Records Request

To provide consent to BHSA to correspond with you via email, please complete the form below:

CONSENT TO E-MAIL COMMUNICATIONS

To request access to your BHSA records, please complete the form below:

REQUEST FOR ACCESS FORM

To provide authorization for BHSA to disclose your protected health information to another entity, please complete the form below:

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

To provide authorization for another entity to disclose your protected health information to BHSA, please complete the form below:

AUTHORIZATION FOR DISCLOSURE TO BHSA

To provide consent to BHSA to provide services via telehealth, please complete the form below. A PDF version may be found HERE.

CONSENT FOR TECHNOLOGY ASSISTED COUNSELING/ONLINE COUNSELING