Medical Records
Protecting the security and privacy of patient information is a priority of Baptist
Memorial Health Care. All information contained within the patient medical record is
considered confidential and is federally protected under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). Medical Records are not released
without the written authorization of the patient, his legal representative, a subpoena
or court order.
To obtain your records, you need to complete an Authorization to Release
Protected Health Information Authorization form.
See
Authorization to Release Protected Health Information Authorization
To read a pdf file:
Download FREE Acrobat Reader here
There may be a charge for the cost of reproduction of your medical records.
To complete the Authorization to Release Protected Health Information (PHI) please
print legibly the following:
1. Name and address of the Baptist facility.
2. Patient name, date of birth, social security number, and address.
3. Name of person or organization you are authorizing to release information to
or request information from.
4. Check one of the following selections:
Disclose my health information to: Name and Address
Obtain/request copies of my health information from: Name and
Address
5. Check the appropriate selection for purpose of use, disclosure, and/or
request.
6. Fill in the specific dates of information to be requested or released.
7. Check appropriate selection of information to be requested or released.
8. Note: Authorization is valid for 90 days from date of signature unless
otherwise specified (blank provided).
9. Date and sign form. Signature is the patient’s or the person authorized to
sign. See note below. Indicate relationship to patient if patient is unable to
sign.
Note:
Minors: If the patient is a minor (less than 18 years of age), the form is
signed by the parent or legal guardian/authorized representative.
Deceased patients: The form must be completed and signed by the
executor, administrator, or personal representative of the estate. If there
is no executor, consent may be given by next-of-kin such as a spouse,
majority consent of adult children, parent or other surviving adult relative.
Legal documents must be presented showing proof of death (if patient did
not die at Baptist) and evidence as person representative of the estate.
10. Mail the authorization form to the Baptist facility (Attention: Health
Information Management Department) where treatment was provided. Or
you may bring it in person to the Health Information Management
Department (HIM).
A list of Baptist facilities and addresses and Department of Release of information
phone numbers is provided below.
BMH- Collierville BMH-Huntingdon
1500 West Poplar 631 R.B. Wilson Dr.
Collierville, TN 38017 Huntingdon, TN 38344
(901) 861-8953 (731) 986-7023
BMH-DeSoto BMH- Union City
7601 Southcrest Parkway 1201 Bishop St.
Southaven, MS 38671 Union City, TN 38261
(662) 772-4315 or (731) 884-8565
(662) 772-4317
BMH-Rehabilitation Germantown BMH- Booneville
2100 Exeter Rd. 100 Hospital St.
Germantown, TN 38138 Booneville, MS 38829
(901) 757- 3471 (662) 720-5064
BMH-Lauderdale BMH- Golden Triangle
326 Asbury Rd. 2520 Fifth St., North
Ripley, TN 38063 Columbus, MS 39701
(731) 221-2413 (662) 244-1126
BMH- Memphis BMJ- North Mississippi
6019 Walnut Grove Rd. 2301 S. Lamar
Memphis, TN 38120 Oxford, MS 38655
(901) 226-5253 (662) 232-8167
BMH-Tipton BMH- Union County
1995 Hwy. 51 South Highway 30
Covington, TN 38019 New Albany, MS 38652
(901) 475-5555 (662) 538-2639
BMH- Hospital for Women Baptist Restorative Care Hospital
6025 Humphreys Blvd. 6019 Walnut Grove Rd., 1 West
Memphis, TN 38120 Memphis, TN 38120
(901) 227-9175 (901)226-0745
Baptist Minor Medical Centers Baptist Trinity Home Care & Hospice
350 N. Humphreys Blvd. 1049 Cresthaven Rd.
Memphis, TN 38120 Memphis, TN 38119
(901) 227-0498 (901) 767-6767
Baptist Home Care & Hospice – North Mississippi Baptist Home Care & Hospice-Tipton
126 Hwy 51 North 1618 Hwy 51 South, Unit C
P.O. Box 1429 Covington, TN 38019
Batesville, MS 38606 (901) 476-0333
(661) 578-8402
Baptist Home Care & Hospice-Huntingdon Medical Alternatives Infusion Pharmacy Services
631 R.B. Wilson Dr. 4565 Shelby Rd.
Huntingdon, TN 38344 P.O. Box 67
(731) 986-3220 Millington, TN 38083
(901)872-2200
Baptist Home Medical Equipment
1600 Century Center Parkway
Suite #101
Memphis, TN 38134
(901) 373-8485
Call the Health Information Management (HIM) Department in advance to confirm
when a copy of the chart will be available for pickup and the copying charge. Factors
such as record availability, size of the record and the volume of requests will affect
response time.
Please bring photo identification with you.
You will need to request other records from the specific department where your
services were provided, such as:
Radiology – copies of films
