Massachusetts General Hospital Medical Records Release Form

Authorization for Release of Protected

or Privileged Health Information

Purpose: (check the appropriate box)

 Medical Care

 Insurance*

 Legal*

 Personal

 School

 Other* (please specify)

*Copying fees may apply

Page 1 of 2

Send by:

 Mass General Brigham Patient Gateway (if available)

 Secure Email

Email Address:

 Fax (provide fax number):

 Paper Copy via Mail

Please print all information clearly in order to process your request in a timely manner.

A. Patient information

Patient Name: Date of Birth:

Medical Record #:

Address: Street: Apt. #:

State: Zip Code:

City:

Preferred Phone #:

B. Permission to share: I give my permission to share my protected health information.

Records from:

Name of Site Location:

Practice Name:

Provider Name:

Send records to (Enter where you would like Mass General Brigham to send your information to):

 Check here if the records are to be mailed to the patient at the above address (section A), otherwise complete the

information below:

Name:

Address:

Telephone Number:

C. Information to be released (please check all that apply, and MUST specify dates):

 Date(s) of Medical Record Abstract (e.g. History &

Physical, Operative Report, Consults, Test Reports,

Discharge Summary)

 Date(s) of Clinic Visit Notes

 Date(s) of Discharge Summary

 Date(s) of Lab Reports

 Date(s) of Operative Reports

 Date(s) of Pathology Reports

 Date(s) of Radiation Reports

 Date(s) of Radiology Reports

 Date(s) of Photographs

 Date(s) of Billing Records

 Other (please specify below and include dates)

Mail or Fax Release Form To:

Release of Information

121 Inner Belt Road, Room 240

Somerville, MA 02143-4453

Fax: 617-726-3661

For questions, contact: 617-726-2361

For copies of radiology images or films,

contact (617) 726-1798 / Fax (617) 724-0264

MGB00087 (06/24)

SCAN TO: PATIENT\AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

D. Please check YES to indicate if you give permission to release the following information if present in your record:

 Yes HIV test results (Patient authorization required for each release request.)

Specify dates

 Yes Genetic Screening test results

Specify type of test

 Yes Substance Use Disorder Treatment Records Protected by Federal Condentiality Rules 42 CFR Part 2

(Federal rules prohibit any further disclosure of this information unless further disclosure is

expressly permitted by written consent of the person to whom it pertains or as otherwise

permitted by 42 CFR Part 2.) This consent may be revoked upon oral or written request.

 Yes

Details of Mental Health Diagnosis and/or Treatment provided by a Psychiatrist, Psychologist, Mental Health

Clinical Nurse Specialist, or Licensed Mental Health Clinician (LMHC) (I understand that my

permission may not be required to release my mental health records for payment purposes)

 Yes Condential Communications with a Licensed Social Worker

 Yes Details of Domestic Violence/ Intimate Partner Abuse Counseling

 Yes Details of Sexual Assault Counseling

E. I understand and agree that:

• Mass General Brigham cannot control how the recipient uses or shares the information, and that laws protecting its

condentiality at Mass General Brigham 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 benets 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 Oce where I

originally submitted it, except:

if Mass General Brigham 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 specied:__________

• I understand that if Mass General Brigham maintains any of my records from outside providers, these will not be

released unless I specically ask for them under “Other” in section C. Please include entity name, provider, and

specic dates if known.

• My questions about this authorization form have been answered

Patient’s Signature: Date:

Print Name:

When 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 of representative to patient:

For Internal Use Only: Information Released/Reviewed By: Date:

Picked up by: Pick-up Identication:  License  State ID  Passport  Other Photo ID