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:
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