Records Request

Please use the following form to initiate a records request. Someone will be in touch with you to gather the remaining information and securely transmit the information to you upon completion of authorization. If you have problems with the link, you can email your request to dr.benson@bhnamc.com.

    [md-form spacing="tight"]
    [md-text label="Requesting Organization/Person"]

    [/md-text]
    [md-text label="Requesting Information For"]

    [/md-text]
    [md-text label="Your Phone Number"]

    [/md-text]
    [md-text label="Your Email Address"]

    [/md-text]
    [md-captcha]
    [anr_nocaptcha g-recaptcha-response]
    [/md-captcha]
    [md-submit]

    [/md-submit]
    [/md-form]