Forms

Release of Radiology Images/CD

To efficiently process your request, please follow the following steps:

1. Mail the completed form with signature to the following address:
Attention: Radiology Dept.
Bonita Community Health Center
3501 Health Center Boulevard
Bonita Springs, FL 34135
2. Fax the completed form with signature to (239) 949-6175.
3. Bring the completed form with signature to the Radiology Department within Bonita Community Health Center.

Click to download the BCHC Release of Radiology Images/CD Form:

Release of Outside Radiology Images/CD

To efficiently process your request, please follow the following steps:

1. Mail the completed form with signature to the following address:
Attention: Radiology Dept.
Bonita Community Health Center
3501 Health Center Boulevard
Bonita Springs, FL 34135
2. Fax the completed form with signature to (239) 949-6175.
3. Bring the completed form with signature to the Radiology Department within Bonita Community Health Center.

Click to download the BCHC Release of Outside Radiology Images/CD Form:

Release of Medical Records

Attention:
This form must be signed in order for us to release copies of your medical records.
The fee for records is a flat fee of $6.50

To efficiently process your request, please return the form in one of the following ways:

1. Mail the completed form with signature to the following address:
Attention: Medical Records
Bonita Community Health Center
3501 Health Center Boulevard
Bonita Springs, FL 34135
2. Fax the completed form with signature to (239) 949-6132.
3. Bring the completed form with signature to the front desk located at the entrance of the Bonita Community Health Center.

Click to download the BCHC Release of Information Form:


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Patient's Bill of Rights

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