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Medical Release Form from BMA

In order to make your records available to other doctors we ask that you print the Medical Release From BMA Form and email it to us. You may mail or drop off the form in person if you wish.   It may take up to three (3) business days to complete the request, so please allow enough time before your visit. Filling out this form will enable us to serve you better and faster.

AUTHORIZATION TO RELEASE MEDICAL RECORDS FROM BERGEN MEDICAL
 

Please Download and complete.  Email or mail to BMA.

Instructions

You will need Adobe® Acrobat Reader version 6.0 or later to use and fill out this form. After Adobe® Acrobat Reader is installed on your computer, download the form by clicking the link above (pdf icon). Once the form is downloaded, you should print it, fill it out and bring it with you. You can also type out the form and print or email it.

Adobe Reader