diff --git a/modules/rest-api/src/blaze/rest_api/routes.clj b/modules/rest-api/src/blaze/rest_api/routes.clj
index 115fee9b1..f57572bdb 100644
--- a/modules/rest-api/src/blaze/rest_api/routes.clj
+++ b/modules/rest-api/src/blaze/rest_api/routes.clj
@@ -64,6 +64,7 @@
    :compile (fn [{:keys [response-type] :response-type.json/keys [opts]} _]
               (condp = response-type
                 :json (output/wrap-output opts)
+                :binary (fhir-output/wrap-binary-output opts)
                 :none identity
                 fhir-output/wrap-output))})
 
@@ -102,6 +103,8 @@
       {:fhir.resource/type name}
       [""
        (cond-> {:name (keyword name "type")}
+         (= name "Binary")
+         (assoc :response-type :binary)
          (contains? interactions :search-type)
          (assoc :get {:interaction "search-type"
                       :middleware [[wrap-db node db-sync-timeout]
diff --git a/modules/rest-api/src/blaze/rest_api/spec.clj b/modules/rest-api/src/blaze/rest_api/spec.clj
index 4caddf582..c92cf7cd9 100644
--- a/modules/rest-api/src/blaze/rest_api/spec.clj
+++ b/modules/rest-api/src/blaze/rest_api/spec.clj
@@ -102,7 +102,7 @@
   boolean?)
 
 (s/def ::operation/response-type
-  #{:json})
+  #{:json :binary})
 
 (s/def ::operation/resource-types
   (s/coll-of string?))
diff --git a/modules/rest-util/src/blaze/middleware/fhir/output.clj b/modules/rest-util/src/blaze/middleware/fhir/output.clj
index 177af7469..593826e1d 100644
--- a/modules/rest-util/src/blaze/middleware/fhir/output.clj
+++ b/modules/rest-util/src/blaze/middleware/fhir/output.clj
@@ -1,8 +1,13 @@
 (ns blaze.middleware.fhir.output
-  "JSON/XML serialization middleware."
+  "FHIR Resource serialization middleware.
+
+  Currently supported formats:
+  * standard: JSON, XML;
+  * special: binary."
   (:require
    [blaze.anomaly :as ba]
    [blaze.fhir.spec :as fhir-spec]
+   [blaze.fhir.spec.type :as fhir-type]
    [blaze.handler.util :as handler-util]
    [clojure.data.xml :as xml]
    [clojure.java.io :as io]
@@ -11,7 +16,8 @@
    [ring.util.response :as ring]
    [taoensso.timbre :as log])
   (:import
-   [java.io ByteArrayOutputStream]))
+   [java.io ByteArrayOutputStream]
+   [java.util Base64]))
 
 (set! *warn-on-reflection* true)
 
@@ -45,6 +51,12 @@
   (with-open [_ (prom/timer generate-duration-seconds "xml")]
     (generate-xml* body)))
 
+(defn- generate-binary [body]
+  (log/trace "generate binary")
+  (with-open [_ (prom/timer generate-duration-seconds "binary")]
+    (when (:data body)
+      (.decode (Base64/getDecoder) ^String (fhir-type/value (:data body))))))
+
 (defn- encode-response-json [{:keys [body] :as response} content-type]
   (cond-> response body (-> (update :body generate-json)
                             (ring/content-type content-type))))
@@ -53,6 +65,12 @@
   (cond-> response body (-> (update :body generate-xml)
                             (ring/content-type content-type))))
 
+(defn- encode-response-binary [{:keys [body] :as response}]
+  (let [content-type (or (-> response :body :contentType fhir-type/value)
+                         "application/octet-stream")]
+    (cond-> (ring/content-type response content-type)
+      body (-> (update :body generate-binary)))))
+
 (defn- format-key [format]
   (condp = format
     "application/fhir+json" :fhir+json
@@ -92,3 +110,17 @@
   ([handler opts]
    (fn [request respond raise]
      (handler request #(respond (handle-response opts request %)) raise))))
+
+(defn handle-binary-response [_opts request response]
+  (case (request-format request)
+    :fhir+json (encode-response-json response "application/fhir+json;charset=utf-8")
+    :fhir+xml (encode-response-xml response "application/fhir+xml;charset=utf-8")
+    (encode-response-binary response)))
+
+(defn wrap-binary-output
+  "Middleware to output binary resources."
+  ([handler]
+   (wrap-binary-output handler {}))
+  ([handler opts]
+   (fn [request respond raise]
+     (handler request #(respond (handle-binary-response opts request %)) raise))))
diff --git a/modules/rest-util/src/blaze/middleware/fhir/resource.clj b/modules/rest-util/src/blaze/middleware/fhir/resource.clj
index 4b417b455..9e391d770 100644
--- a/modules/rest-util/src/blaze/middleware/fhir/resource.clj
+++ b/modules/rest-util/src/blaze/middleware/fhir/resource.clj
@@ -1,5 +1,8 @@
 (ns blaze.middleware.fhir.resource
-  "JSON/XML deserialization middleware."
+  "FHIR Resource deserialization middleware.
+
+  Currently supported formats:
+  * standard: JSON, XML."
   (:require
    [blaze.anomaly :as ba :refer [if-ok when-ok]]
    [blaze.async.comp :as ac]
diff --git a/modules/rest-util/src/blaze/middleware/output.clj b/modules/rest-util/src/blaze/middleware/output.clj
index 75268f186..3b479c5d8 100644
--- a/modules/rest-util/src/blaze/middleware/output.clj
+++ b/modules/rest-util/src/blaze/middleware/output.clj
@@ -1,5 +1,8 @@
 (ns blaze.middleware.output
-  "JSON serialization middleware."
+  "Non-FHIR serialization middleware.
+
+  Currently supported formats:
+  * standard: JSON."
   (:require
    [jsonista.core :as j]
    [ring.util.response :as ring]))
diff --git a/modules/rest-util/test/blaze/middleware/fhir/output_test.clj b/modules/rest-util/test/blaze/middleware/fhir/output_test.clj
index 6322d57eb..a2b2312b9 100644
--- a/modules/rest-util/test/blaze/middleware/fhir/output_test.clj
+++ b/modules/rest-util/test/blaze/middleware/fhir/output_test.clj
@@ -1,9 +1,11 @@
 (ns blaze.middleware.fhir.output-test
   (:require
+   [blaze.byte-string :as bs]
    [blaze.fhir.spec :as fhir-spec]
    [blaze.fhir.spec-spec]
+   [blaze.fhir.spec.type :as fhir-type]
    [blaze.fhir.test-util]
-   [blaze.middleware.fhir.output :refer [wrap-output]]
+   [blaze.middleware.fhir.output :refer [wrap-binary-output wrap-output]]
    [blaze.module.test-util.ring :refer [call]]
    [blaze.test-util :as tu]
    [clojure.data.xml :as xml]
@@ -27,6 +29,18 @@
    (fn [_ respond _]
      (respond (ring/response {:fhir/type :fhir/Patient :id "0"})))))
 
+(defn binary-resource-handler-200
+  "A handler which uses the binary middleware and just returns
+  a binary resource."
+  [{:keys [content-type data] :as _body}]
+  (wrap-binary-output
+   (fn [_ respond _]
+     (respond
+      (ring/response
+       (cond-> {:fhir/type :fhir/Binary}
+         data (assoc :data (fhir-type/base64Binary data))
+         content-type (assoc :contentType (fhir-type/code content-type))))))))
+
 (def resource-handler-304
   "A handler which returns a 304 Not Modified response."
   (wrap-output
@@ -205,5 +219,37 @@
       [:headers "Content-Type"] := "application/fhir+xml;charset=utf-8"
       [:body parse-xml :issue 0 :diagnostics] := "Invalid white space character (0x1e) in text to output (in xml 1.1, could output as a character entity)")))
 
+(deftest binary-resource-test
+
+  (testing "with data and with content type"
+    (given (call (binary-resource-handler-200 {:content-type "text/plain" :data "MTA1NjE0Cg=="}) {:headers {"accept" "text/plain"}})
+      :status := 200
+      [:headers "Content-Type"] := "text/plain"
+      [:body bs/from-byte-array] := #blaze/byte-string"3130353631340A"))
+
+  (testing "with data and without content type"
+    (given (call (binary-resource-handler-200 {:content-type nil :data "MTA1NjE0Cg=="}) {:headers {"accept" "text/plain"}})
+      :status := 200
+      [:headers "Content-Type"] := "application/octet-stream"
+      [:body bs/from-byte-array] := #blaze/byte-string"3130353631340A"))
+
+  (testing "without data and with content type"
+    (given (call (binary-resource-handler-200 {:content-type "text/plain"}) {:headers {"accept" "text/plain"}})
+      :status := 200
+      [:headers "Content-Type"] := "text/plain"
+      :body := nil))
+
+  (testing "without data and without content type"
+    (given (call (binary-resource-handler-200 {:content-type nil}) {:headers {"accept" "text/plain"}})
+      :status := 200
+      [:headers "Content-Type"] := "application/octet-stream"
+      :body := nil))
+
+  (testing "without body at all"
+    (given (call (binary-resource-handler-200 nil) {:headers {"accept" "text/plain"}})
+      :status := 200
+      [:headers "Content-Type"] := "application/octet-stream"
+      :body := nil)))
+
 (deftest not-acceptable-test
   (is (nil? (call resource-handler-200 {:headers {"accept" "text/plain"}}))))