Please upload this page to the portal,
or fax to 781-890-2177
If you have questions please call
781-890-2133
Records Release
Print Name:_______________________________________________________________Date of Birth:_____________________________
Home Address Street:___________________________________________________________________Apt#________________________
City:________________________________________________State:____________________________Zip:_________________________
By Signing this release form, I authorize Boston Sports & Shoulder Center , to send a copy of my medical records to the following:
Share to:
Name or Office: ________________________________________
Street:________________________________________________
Apt#:__________________City:___________________________
State:___________________________Zip:__________________
Phone: _______________________________________________
Fax: _________________________________________________
Purpose:
Medical care
Insurance
Legal
Personal
School
Other (please specify): ____________________________
Send via:
Portal
Fax provided
Mail paper copy address provided
Medical Records to be sent (please select):
ALL of my medical records (excluding imaging done in the Waltham office)
Imaging done in the Waltham office ONLY*
ONLY the following medical records:___________________________________________________________________________
Special medical records to be sent (please check any/all the apply):
Drug and alcohol abuse records
Mental health records
HIV/AIDS records
Sexual abuse/ assault and domestic violence records
Sexually-transmitted disease records
I understand and agree that:
● Boston Sports & Shoulder Center cannot control how the recipient uses or shares the information, and that laws protecting its
confidentiality at Boston Sports & Shoulder Center may or may not protect this information once it has been released to the
recipient.
● This authorization is voluntary
● My treatment, payment, health plan enrollment, or eligibility for benefits will not be affected if I do not sign this form
● I may cancel this authorization at any time by submitting a written request to the Department or Office where I originally submitted
it, except: if Boston Sports & Shoulder Center has already processed the request (for example, once information is released, it will
not be retrieved) if I signed this authorization as a condition of obtaining insurance. Other laws may provide the insurer with a right
to contest a claim under the policy or the policy itself
● This authorization will automatically expire 6 months from the date signed unless otherwise specified:______________________
● I understand that if Boston Sports & Shoulder Center maintains any of my records from outside providers, these will not be released
unless I specifically ask for them under “Other” in section C. Please include entity name, provider, and specific dates if known.
● My questions about this authorization form have been answered
Patient Signature: __________________________________________________________________________Date:____________________
Print Name: _________________________________________________________
When a patient is a minor, or is not competent to give consent, the signature of a parent, guardian, or other legal representative is required.
Signature of Legal Representative: _____________________________________________________________Date:___________________
Print Name: ______________________________________________________Relationship to patient:______________________________
* Imaging done at New England Baptist Hospital, Boston or Dedham, needs to be requested via: https://nebhpatient.ambrahealth.com/access
For Internal Use Only : Information Released/Reviewed By:________________________________________________ Date:_______________
Picked up by:_______________________ Pick-up Identification: ◻ License ◻ State ID ◻ Passport ◻ Other Photo ID____________________
