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180 Engle St, Englewood NJ 07631 View Locations

Medical Release Records to Self

If you need your records released to yourself please fill out the Medical Release Form to Self and send it to us via email (bmanurse1@bergenmedical.com) or fax (201-568-8936)  so that we may process your request. 

AUTHORIZATION TO RELEASE MEDICAL RECORDS TO SELF

Please Download and complete. Email (bmanurse1@bergenmedical.com) , fax  (201-568-8936) or mail to the office.

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.

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