Medical Records/Proxy Request Forms

Release of Medical Records

You may obtain a copy of your complete medical record, including inpatient hospital visits and any outpatient and provider visits through BHS Medical Records Department Monday through Friday from 8 am to 4 pm. 724-284-4530.

Please complete the appropriate Release of Information form and mail or fax to BHS medical records department. There is no charge to obtain your records.

Butler Memorial Hospital Release of Information
Attn: Medical Records
One Hospital Way
Butler, PA 16001

(Fax) 724-284-4532

• Authorization to Release Protected Health Information

Proxy Request

You may appoint family members or other designated individuals to act on the patient’s behalf. Proxy access allows access to another’s record and features on behalf of the patient (such as making appointments, viewing appointments, viewing health summaries and billing information).

Proxy request forms must be signed by both the proxy and the patient and provide proof of guardianship to BHS medical records.

If requesting proxy access, please complete the proxy request forms for children age 0-12.

Proxy access must be re-established on the patient’s 13^th birthday and 18^th birthday with consent of both patient and proxy.

You can drop off your form by mail or email all Proxy Request forms to:
*please note proof of identification must be included with your Proxy Request form

Butler Memorial Hospital Release of Information
Attn: Medical Records
One Hospital Way
Butler, PA 16001

(Phone) 724-284-4530
(Fax) 724-284-4532
medicalrecords@butlerhealthsystem.org

• My BHS Health Proxy Access: Expiration/Removal Form
• My BHS Health Proxy Access: Power of Attorney/Legal Guardian Proxy Request Form- Adult Patient (For patients under 13 years of age)
• My BHS Health Proxy Access: Adult Authorization Form
• My BMH Health Proxy Access: Power of Attorney/Legal Guardian, Proxy Request Form - Adult Patient (For adult incapacitated patients)