Patients and/or legal representatives needing to request a copy of medical records should submit requests in writing by completing the Release of Information form below.

Henry Ford Health Behavioral Health Hospital ROI

Please ensure the form is filled out completely and includes:

Name, date of birth and demographic information
Delivery method, including how you would like records to be sent (fax, email, mail).
Where records need to be sent, including address, phone number, fax or email address
Purpose of the request
A description of the records that should be included and date range
Signature of the individual authorized to release medical records

If the requester is someone other than the patient, please include supporting documentation such as guardianship or Durable Power of Attorney.

Submit completed forms to:

Henry Ford Behavioral Health Hospital

Attn: HIM

7100 BERRYHILL STREET

West Bloomfield, MI. 48322

Fax: (248) 200-5780

Email: HFBMedicalRecordsROI@HenryFordBehavioral.com

If you are requesting to pick up a paper copy of your medical record, please call 248-398-3200 x665 to schedule a date and time.